Depression Chapter 5
Transcription
Depression Chapter 5
O N TA R I O W O M E N ’ S H E A LT H E Q U I T Y R E P O R T Depression Chapter 5 AUTHORS INSIDE Elizabeth Lin, PhD Natalia Diaz-Granados, MSc Donna E. Stewart, MD, FRCPC Anne E. Rhodes, PhD Naira Yeritsyan, MD, MPH Ashley Johns, MSc Minh Duong-Hua, MSc Arlene S. Bierman, MD, MS, FRCPC • Background Measures • Primary and Specialty Outpatient Care • Acute and Specialty Inpatient Care Improving Health and Promoting Health Equity in Ontario ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 September 2009 • Volume 1 Ontario Women’s Health Equity Report Improving Health and Promoting Health Equity in Ontario Acknowledgements The POWER Study is funded by Echo: Improving Women’s Health in Ontario, an agency of the Ministry of Health and Long-Term Care. This report does not necessarily reflect the views of Echo or the Ministry. The POWER Study is a partnership between the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto. We would like to thank all the people who helped with this chapter. For details, please see the Preliminary section of Volume 1 at www.powerstudy.ca. Publication Information © 2009 St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the proper written permission of the publisher. Canadian cataloguing in publication data Project for an Ontario Women’s Health Evidence-Based Report: Volume 1 Includes bibliographical references ISBN: 978-0-9733871-1-7 How to cite this publication The production of Project for an Ontario Women’s Health Evidence-Based Report: Volume 1 was a collaborative venture. Accordingly, to give credit to individual authors, please cite individual chapters and titles, in addition to the editors and book title. For this chapter: Lin E, Diaz-Granados N, Stewart D, Rhodes A, Yeritsyan N, Johns A, Duong-Hua M, Bierman AS. Depression. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. For this volume: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. The POWER Study Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital 30 Bond St. (193 Yonge St., 6th floor) Toronto, ON, M5B 1W8 Tel: (416) 864-6060, Ext 3946 Fax: (416) 864-6057 [email protected] www.powerstudy.ca Cover photo © www.istockphoto.com Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression TABLE OF CONTENTS Executive Summary.................................................................................... 2 Introduction............................................................................................... 10 List of Exhibits........................................................................................... 15 A Guide to Reading Maps........................................................................ 18 Background Measures.............................................................................. 21 Primary and Specialty Outpatient Care . ................................................ 40 Acute and Specialty Inpatient Care ........................................................ 52 Chapter Summary of Findings................................................................. 70 Discussion.................................................................................................. 73 Improving Depression Care: Different Approaches.................................... 80 Appendix 5.1 Indicators and Their Links to Provincial Strategic Objectives............................................................ 84 Appendix 5.2 Indicators and Their Sources . .......................................... 87 Appendix 5.3 How the Research was Done............................................ 90 References............................................................................................... 100 Improving Health and Promoting Health Equity in Ontario 1 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Executive Summary ISSUE Depression, a common chronic condition, is a tremendous emotional and financial burden for people who suffer from it, their families and society. It is the leading cause of diseaserelated disability among women, according to the World Health Organization.1 Depression has a vast economic impact, and is population-based Ontario Mental Health Supplement responsible for lost productivity, increased disability (1990) found higher disability among women aged claims and greater use of health care services. In this 15-19 compared to men in that age group: women chapter we examine the patterns of depression care in reported 3.4 disability days due to mental health the province and how they differ by gender, income, compared to 1.1 days reported by men.20 In addition, age and where one lives. women often report different depressive symptoms than men do, such as having more anxiety, appetite There are effective treatments for depression that disturbances and sleep changes.21 Although there can improve quality of life and health outcomes is no gender difference in the risk of recurrence of among those with the disease. Many people with depression,15 women have longer recurrent episodes. depression go untreated2-5 and some who are On the other hand, men are more likely to suffer from treated may receive suboptimal care.6, 7 Gender and socioeconomic position are associated both with the risk of developing depression and the type of depression alcohol and substance dependence22 and have higher rates of completed suicide.23 care received.8-11 Quality improvement interventions Some women are at increased risk of depression have been shown to improve quality and outcomes of and special efforts need to be made to provide care depression care. 12-14 and support for them. There is evidence that some immigrant and ethnic minority women may be at Women in developed countries are twice as likely to increased risk of depression, therefore cultural sensitivi- suffer from depression as men10, 15-17 and research ties must be considered in delivering depression services. shows numerous differences in how the two sexes experience the disease. Women tend to have onset of depression at a younger age and experience greater province may be large since approximately 27 percent of Ontario’s population is foreign-born and 40 percent severity of illness than men. They also report more functional impairment, poorer social adjustment and worse quality of life.18, 19 A report using data from the 2 The need for culturally sensitive depression services in the are first- or second-generation immigrants.24, 25 Rural women and men may be less likely to receive treatment Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Executive Summary due to limited availability of services.4 Finally, women in 8 lower-income households or who live in low-income neighbourhoods26 were also significantly more likely to have depression than those in higher-income brackets or neighbourhoods. Targeting depression services to those with the highest 'need' is essential to reducing the burden of this treatable disorder and achieving the best possible outcomes. study This chapter uses a set of evidence-based indicators to assess gender, income, age and regional differences in depression care among Ontarians living with depression. Indicators were chosen by a Technical Expert Panel (TEP) using a modified Delphi process (see The POWER Study Framework, chapter 2). We used the continuum of care (Figure 1) to guide the identification of important gender gaps in depression care and a review of relevant measures from the published and grey literature (for ABOUT THIS CHAPTER details see Appendix 5.3). These indicators are intended The chapter has three sections: understand where there are sex and sociodemographic A.Background Measures This section provides a snapshot of the need for, use and supply of mental health care services in Ontario. B.Primary and Specialty Outpatient Care Indicators to help administrators, policy makers and providers disparities in depression care, create new policies and programs for dealing with gender gaps and reduce the barriers that keep both women and men from getting the depression care they need. We used multiple data sources in this report including the Canadian Community Health Survey (CCHS), Cycle 1.1 (2000/01); Daily Census Summary Report Mental This section presents and discusses indicators Health Beds online, Ministry of Health and Long-Term of depression care in outpatient settings. Care (MOHLTC) Health Data Branch; Canadian Institute Because of data limitations, only care provided for Health Information Discharge Abstract Database by Ontario physicians paid by fee-for-service (CIHI-DAD); Ontario Health Insurance Plan (OHIP) could be measured. physician claims data; National Ambulatory Care Reporting System (NACRS); Ontario Drug Benefit (ODB) C.Acute and Specialty Inpatient Care Indicators database; Institute for Clinical Evaluative Sciences (ICES) Physician Database (IPDB); ICES Mother-Baby Linked This section covers indicators of depression database (MOMBABY) and Statistics Canada 2001 care provided in inpatient settings and on Census. A complete list of the indicators reported in transition back to the community. this chapter and their data sources can be found in Appendix 5.2. All indicators are reported at the provincial level and at the Local Health Integration Network (LHIN) level when sample size allowed. All analyses were stratified by sex (where applicable), and then by age, income or rural/urban residency. Age-adjustment was done using indirect standardization. Appendix 5.3 provides a description of the research methods. Improving Health and Promoting Health Equity in Ontario 3 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Key Findings In this chapter we present background measures of the There were also differences in which service sectors need, use and supply of depression care in Ontario, as were used. Women and men from the lowest-income well as indicators of inpatient and outpatient depression areas were almost twice as likely to be hospitalized for care. Figure 5 provides a summary of where sex, depression but incurred slightly lower average costs for income, age and regional differences were found. OHIP core mental health services compared to Ontarians living in the highest-income areas (Exhibit 5A.9). Overall, we found many instances where depression care was suboptimal for everyone. Less than half of women and men with probable depression had a physician visit for this condition. Many older adults who started on antidepressant therapy did not receive the recommended number of follow up visits for management (i.e., three or more visits within 12 weeks of starting medication). One in three women and men who were hospitalized for depression did not have a follow up physician visit for depression within 30 days of hospital discharge and nearly one in five were seen in the emergency department in this time frame, indicating suboptimal care coordination during care Rural residents were more likely to be hospitalized for depression while urban dwellers accounted for proportionately greater OHIP costs for mental health care (Exhibit 5A.10). A comparison of need, use and supply across LHINs suggested that the geographic patterns of use reflected the geographic distribution of supply more than need. We report results for several indicators of depression care. For some indicators, we found no significant sex differences. Women and men with probable depression had similar rates of having a physician visit for depression within a one-year period (Exhibit 5B.1). transitions. We found differences in the prevalence of depression—one of the important markers of need for depression care—across sex, income, age and geography. We also found differences in the use of services for both depression and mental health Men and women aged 66 and older, starting on a new course of antidepressants, were equally likely to have had the recommended number of follow up visits (Exhibit 5B.4). And women and men who were hospitalized for depression were equally likely to be in general. In some cases, the prevalence patterns readmitted for depression (Exhibit 5C.12) or to have were similar to the service use patterns. For example, visited the emergency department (Exhibit 5C.8) in the women had higher rates of both depression and use month after they were discharged. of Ontario Health Insurance Plan (OHIP) core mental health services (Exhibit 5A.8). In other cases, however, they were not. Low-income women were more likely to report probable depression (Exhibit 5A.1) but had similar rates of use of OHIP core mental health services as higher-income women (Exhibit 5A.5). 4 There were some gender differences. Among people who were hospitalized for depression, women were more likely than men to have seen a physician for depression post-discharge (Exhibit 5C.5). For those who were seen within 30 days of discharge, there was no Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Executive Summary difference in how long women and men took to get a to do so more quickly) than those from lower-income follow up visit within the first 30 days after discharge. neighbourhoods (Exhibit 5C.1). And, men living in the Beyond 30 days, men took somewhat longer to have a lowest-income neighbourhoods were more likely than physician visit. men from the highest-income neighbourhoods to visit A few indicators showed differences in depression care associated with age. Ontarians with probable an emergency department in the month after a hospital stay for depression (Exhibit 5C.8). depression aged 45-64 were the most likely to visit Some rural/urban differences were found. Urban a physician for depression (Exhibit 5B.2), although dwellers were more likely to have a post-discharge they were not the group with the highest prevalence. physician visit for depression than those from rural areas Among older Ontarians starting antidepressants, age (Exhibit 5C.2). Also, men from rural areas were more was associated with a decreasing likelihood of adequate likely to visit an emergency department after discharge physician follow up (i.e., three or more visits within than those from urban areas. the 12 weeks after starting medication) for depression Variations across Local Health Integration Networks (LHINs) were found for a number of indicators, and these represented the largest (Exhibit 5B.5) but an increasing likelihood of physician visits for any reason. Disparities by income were found for several indicators. Among women with probable depression, those with lower annual household incomes were more likely to see a physician for depression than those with higher annual household incomes (Exhibit 5B.1). Among women aged 66 and older, those from lower-income neighbourhoods who started antidepressants were less likely to have had the recommended number of follow up physician visits than women from higher-income neighbourhoods (Exhibit 5B.4). Among Ontarians who had been hospitalized for depression, people who lived in higher-income neighbourhoods were more likely to disparities reported in this chapter. Differences between the highest and lowest LHINs ranged from roughly one-and-a-half times as large (physician visits for depression within 30 days of hospital discharge) (Exhibit 5C.3) to twice as large (percentage of adults aged 66 and older, starting a new course of antidepressants who had three or more physician visits for depression within 12 weeks of starting medication (Exhibit 5B.6); 30-day post-discharge rate of emergency department visits (Exhibit 5C.10)) to as high as four times as much (30-day readmission rate for depression (Exhibit 5C.13)). have a post-discharge physician visit for depression (and Improving Health and Promoting Health Equity in Ontario 5 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Key Messages Our findings support the need to re-evaluate care for • Explore developing care models for specific underserved depression in Ontario along several fronts and at several groups (including men, younger people, the elderly, levels. The indicators chosen for this chapter arise from people with low incomes and people who live in rural evidence-based recommendations or guidelines for areas) and evaluate their impact, especially when appropriate depression care and suggest specific and combined with targeted outreach; immediate aspects of clinical practice that need further examination and improvement. The distribution and organization of existing resources—important elements in supporting the continuity of care envisioned across • Implement models to better coordinate care across care transitions between sectors, particularly from hospital to home; • Coordinate depression care with other types of health the decades of mental health reform in Ontario and an obvious focus for the newly organized LHINs—will care, particularly chronic disease management, so that also play important roles in both improving access and patients with more than one health problem do not delivering more appropriate and effective courses of receive fragmented care; care in the immediate and medium term. In particular, • Evaluate the effectiveness of care through routine gender a wider adoption of collaborative care models for and equity analyses of indicators of depression care and depression deserves serious consideration. its outcomes; • Improve data capacity to better measure access, The following actions could help to improve access to, and the quality of, depression care quality and outcomes of depression care across the in Ontario: care continuum. • Develop and support collaborative care models in primary care and across depression care sectors; 6 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Executive Summary Key Findings by Section SECTION A | Background Measures • Women and men from the lowest-income areas were almost twice as likely to be hospitalized for depression Need • Women were twice as likely to have probable depression as men in Ontario (Exhibit 5A.3). This finding is consistent with the evidence from the literature from Canada and from other countries such 10, 15-17 as the US and UK. • There were regional and income differences in the prevalence of probable depression. Individuals living in the lowest-income neighbourhoods were more likely but incurred slightly lower average costs for OHIP mental health services than those from higher-income areas (Exhibit 5A.9). • Rural and urban residents used services differently. Rural residents were more likely to be hospitalized for depression while urban dwellers accounted for a greater proportion of OHIP costs per capita for mental health care (Exhibit 5A.10). to have probable depression than those living in the Supply highest-income neighbourhoods (Exhibit 5A.1). • Resources such as physician supply and psychiatric • There was no difference in the prevalence of hospital beds varied markedly across Local Health probable depression based on whether people lived in Integration Networks (LHINs). The differences between rural or urban areas (Exhibit 5A.10). the highest and lowest rates per 100,000 population • Women with probable depression were somewhat more likely to report comorbid chronic medical conditions than men. However, there were few differences by sex in self-rated health or self-reported functioning among those with probable depression (Exhibit 5A.3). Use • There were distinct sex differences in use of services among LHINs ranged from twice as many general practitioners (GPs) or family physicians (FPs) to three times as many hospital beds and 12 times as many psychiatrists (Exhibits 5A.11, 5A.12). Patterns of need, use and supply • Patterns of service use appeared to reflect supply more than need (Exhibit 5A.13). for depression. Women were between one and a half SECTION B | Primary and Specialty to two times more likely than men to use OHIP core mental health services—a pattern consistent with their higher rates of depression (Exhibit 5A.8). • Although women from lower-income areas were more likely to have probable depression than those from higher-income areas, they had similar rates of use of OHIP core mental health services (Exhibit 5A.5). However, women from higher-income neighbourhoods incurred greater OHIP core mental health costs per capita than women from lower-income neighbourhoods (Exhibit 5A.6). Improving Health and Promoting Health Equity in Ontario Outpatient Care Care for Ontarians with probable depression • Sixty percent of Ontarians with probable depression did not have a physician visit for depression care within the year after they were interviewed. • Among those with probable depression, women and men had similar visit rates of physician visits for depression—41 percent of women and 37 percent of men had at least one physician visit for depression within a year of their survey interview. 7 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 • Women with probable depression who had lower • Women were somewhat more likely than men to have annual household incomes were more likely to see a seen a physician for depression within 30 days after physician for depression than those with higher annual discharge from hospital (65 percent of women versus household incomes (Exhibit 5B.1). 60 percent of men). This pattern held true across neighbourhood income levels (Exhibit 5C.1), rural/ • Ontarians aged 45-64 with probable depression were the most likely to visit a physician for depression (Exhibit 5B.2), although they were not the age group with the highest disease prevalence. urban residency (Exhibit 5C.2), and almost all LHINs (Exhibit 5C.4). • One year post-discharge, 10 percent of women and 14 Care for older Ontarians starting a new course of percent of men had not seen a physician for depression. • There was no difference in how long women and men antidepressant medication • Older Ontarians who started antidepressant medication took to get a follow up visit during the first 30 days after had low rates of adequate physician follow up for discharge. Beyond 30 days men took somewhat longer depression (i.e., three or more visits within 12 weeks of to have a physician visit (Exhibit 5C.6). starting medication); 9.5 percent for women and 9.9 • People who lived in higher-income neighbourhoods percent for men, although roughly 85 percent had at least three physician visits for any reason in the important first 12 weeks after starting antidepressants. and those who lived in urban areas were more likely to have a post-discharge physician visit for depression than those from lower-income neighbourhoods or rural areas. The largest differences, however, were • Among these older Ontarians, increased age was associated with a decreasing likelihood of having had across LHINs, where the rates ranged from 50 percent three physician visits for depression after starting anti- to 72 percent (Exhibit 5C.3). depressant medication (Exhibit 5B.5) but an increasing likelihood of physician visits for any reason. Emergency department visits for depression (not resulting in readmission) after a discharge from a • Older women from lower-income neighbourhoods hospital stay for depression were less likely to have had the recommended number • Women and men were equally likely to have had an of follow up physician visits for depression after emergency department visit within 30 days (17 percent starting their new antidepressants than women from and 18 percent, respectively) of discharge after a hospital higher-income neighbourhoods (Exhibit 5B.4). stay for depression. Care for postpartum women • Men living in the lowest-income neighbourhoods were • Twenty percent of Ontario women who gave birth more likely to visit an emergency department within 30 had a physician visit for depression within one year days of discharge after a hospital stay for depression than following delivery (Exhibit 5B.7). men from higher-income neighbourhoods (Exhibit 5C.8). SECTION C | Acute and Specialty Inpatient Care Physician visits for depression after a discharge • Men from rural areas were more likely to have had an emergency department visit within 30 days of discharge after a hospital stay for depression than those from from a hospital stay for depression • One in three Ontarians did not have a physician visit for urban areas. depression within 30 days of discharge after a hospital stay for depression. 8 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Executive Summary • Sex disparities occurred within age groups; the youngest women had a higher rate of emergency department visits in the 30 days post-discharge after a hospital stay for depression than men that age, but men aged 45-64 had higher rates of use than women (Exhibit 5C.9). • The largest difference in the percentage of women and men who had an emergency department visit in the 30 days post-discharge after a hospital stay for depression was across LHINs. The highest rate (21 percent) was almost double the lowest rate (11 percent) (Exhibit 5C.10). Readmission to hospital for depression • Women and men were equally likely to be readmitted to hospital for depression in the 30 days after a previous hospital stay (7.6 percent for each). There were few differences in 30-day readmission rates across age groups, neighbourhood income levels (Exhibit 5C.12) and rural/urban residency. • There were differences across LHINs, however, where 30-day readmission rates ranged from 2.9 percent to 11.9 percent (Exhibit 5C.13). © www.istockphoto.com Improving Health and Promoting Health Equity in Ontario 9 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Introduction Depression, a common chronic condition, is a tremendous emotional and financial burden for people who suffer from it, their families and society. It is the leading cause of disease-related disability among women, according to the World Health Organization.1 Depression has a vast economic impact, and is functional impairment, poorer social adjustment and responsible for lost productivity, increased disability worse quality of life.18, 19 A report using data from the claims and greater use of health care services. population-based Ontario Mental Health Supplement (1990) found higher disability among women aged There are effective treatments for depression that 15-19 compared to men in that age group: women can improve quality of life and health outcomes reported 3.4 disability days due to mental health for those with the disease. Many people with compared to 1.1 days reported by men.20 In addition, depression go untreated2-5 and some who are women often report different depressive symptoms treated receive suboptimal care.6, 7 Gender and than men, such as having more anxiety, appetite socioeconomic position are associated both with disturbances and sleep changes.21 Although there the risk of developing depression and the type of is no gender difference in the risk of recurrence of depression care received.8-11 Quality improvement interventions have been shown to improve quality and depression,15 women have longer recurrent episodes. outcomes of depression care.12-14 On the other hand, men are more likely to suffer from In Ontario, in a 12-month period, 4.8 percent of rates of completed suicide.23 alcohol and substance dependence22 and have higher the overall population will suffer from depression. Ideally the supply and use of health care services for However, the problem is not evenly distributed: 6.1 percent of women and 3.5 percent of men report being depressed.8 Ontario’s rates of depression are similar to the rest of Canada.27, 28 In this chapter we examine the patterns of depression care in the province and how they differ by gender, income, age and where one lives. and women who were single or divorced, those with a higher education and those born in Canada were most likely to report using health services for their mental found that more women reported unmet needs for suffer from depression as men,10, 15-17 and research depression care (5.6 percent) than men (3.4 percent).30 shows numerous differences in how the two sexes experience the disease. Women tend to have onset of 10 after adjusting for variation in need, that women, men the Canadian Community Health Survey, Cycle 1.2 Women in developed countries are twice as likely to severity of illness than men. They also report more prevalence and severity of illness.29 One study found, health problems.11 Another study that used data from Gender Differences in Depression depression at a younger age and experience greater depression should reflect need and be related to the They also found that women were two-to-three times more likely than men to experience barriers to accessibility and acceptability of seeking mental health Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Introduction care. Women’s access to care was limited due to cost, transportation, competing responsibilities and language limitations. Attitudes of providers and the health system toward mental illness also affected the acceptability of services. Some women are at increased risk of depression and special efforts need to be made to provide care and support for them. There is evidence that some immigrant and ethnic minority women may be at increased risk of depression, therefore cultural sensitivities must be considered in delivering depression services. The need for culturally sensitive depression services in the province may be large since approximately 27 percent of Ontario’s population is foreignborn and 40 percent are first- or second-generation immigrants.24, 25 Rural women and men may be less likely to receive treatment due to limited availability of services.4 Finally, women in lower-income households8 or those who live in low-income neighbourhoods26 © www.istockphoto.com were also significantly more likely to have depression than those in higher-income brackets or neighbourhoods. Targeting depression services to those with the highest 'need' is essential to reducing the burden of this treatable disorder and achieving the best possible outcomes. quality improvement programs to be equally effective in improving treatment outcomes and quality of life for women and men,35 but sex disparities remained for other outcomes such as unmet need for treatment, burden of depression and quality of life years lost.35, 36 Quality Improvement and Depression Care Quality improvement programs for depression care have shown that mental health services can be improved for depression, but it is not clear whether These studies also reported that the type of quality improvement intervention—whether it facilitated medication management, psychotherapy or both—may benefit women and men differently. they benefit men and women equally.13, 31-33 Studies To reduce the gender inequity in the use of mental of quality improvement programs for other treatments, health services, we need to examine the quality of 34 including haemodialysis, show that sex disparities mental health care. Ontarians get formal mental can be reduced for some medical outcomes by health care through family physicians, psychiatrists, monitoring patient outcomes, and providing feedback general hospitals, specialty and tertiary care hospitals, on performance to health care providers. However, few community mental health programs and mental studies have examined whether quality improvement health provider private practices.37 Although care programs for depression care affect the sexes for depression is also provided by other profession- differently, and those that have, have focused mainly als such as psychologists, social workers and nurses, on outpatient primary care services. One study found as well as by self-help and peer-support programs, we Improving Health and Promoting Health Equity in Ontario 11 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 did not include these in the chapter because there are discussion paper for the province’s ten-year strategy for no system-wide, linkable data on these services. The mental health and addictions (Every Door is the Right quality of mental health services should be monitored Door: Towards a ten-year mental health and addictions using structural, process and outcome indicators.38-41 strategy).56 In addition, Echo: Improving Women’s There is specific national and international attention Health in Ontario, an agency of the Ontario MOHLTC, on improving the access to and use of depression has sponsored consultations across the province on care resources.42-45 Prior reports, however, have not improving the health and health care of people with looked at indicators that assess the broad spectrum of depression. All of these initiatives share a common goal 'behavioural' health care—that is, the care delivered of ensuring equitable access to quality mental health by community mental health workers such as social care. The indicators in this chapter were selected based workers, therapists and psychologists46 and none have on that same goal with the intent that they will support assessed whether gender inequities exist in the process the move from policy to implementation. of the delivery of depression services. We believe it is vital to consider the impact of gender because of the significant differences in men's and women’s needs for depression care and the differences in how they seek health care. The impact of gender inequity on performance of indicators for depression care should be considered along with other factors that influence need and use of care for depression including age, income and other socioeconomic factors.47, 48 Gender differences in treatments, other process-related factors and outcomes should be considered by policy makers and program planners in developing services for those with the highest needs and removing barriers that make gender and sociodemographic inequity This chapter looks at gender equity in health services for Ontarians living with depression. Indicators were chosen by a Technical Expert Panel (TEP) using a modified Delphi process and an explicit set of indicator selection criteria (see The POWER Study Framework, chapter 2). We used the continuum of care shown below (Figure 1) to guide the identification of important gender gaps in depression care and a review of relevant measures from the published and grey literature. These measures were then narrowed down, first by the TEP and then by determining what was feasible to measure using available Ontario data (for details see Appendix 5.3). These indicators are intended to help administrators, worse.49-53 policy makers and providers understand where there are Since 1988, when the pivotal Graham report was released, Ontario has made efforts to develop coherent, long-range policies and planning for the mental health system.54 Current efforts include the MOHLTC Mental Health System Report Card55 and the recently released 12 Delivering Depression Care in Ontario sex disparities in depression care, create new policies and programs for dealing with the worst gender gaps and reduce the barriers that keep both women and men from getting the depression care they need. Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Introduction Figure 1: Continuum of Depression Care CONTINUUM OF DEPRESSION CARE Prevention/ health promotion Community services/ supports Primary care Specialty outpatient care Acute hospital care Specialty hospital care There is no single cause for depression, which is part tional, to stabilize them to the point where they can of the challenge in providing care for it. Clinicians benefit from community and outpatient services and and researchers believe many factors play a role in then effect a smooth discharge. determining who develops depression and how the course of their illness runs. These diverse factors include genetics, childhood experiences, lifestyle and social circumstances; several may occur together in people who are clinically depressed. There is no single course for depression. Some people have only one depressive episode in their life while others experience recurring episodes of varying severity. Ideally, depression should be treated with a range of integrated and coordinated services, along the continuum of care (Figure 1). Prevention and health promotion provide information and initiatives to reduce the risk of developing or relapsing into depression. Community services and supports help people whose condition is relatively stable to cope with Data limitations prevented us from measuring prevention and promotion and community services and supports (see ‘What we can’t measure’ in the Discussion). The results for the remaining indicators are organized into three sections: • Background Measures. The indicator selection process identified a number of measures that were not specifically related to individual treatment of depression. They were, however, important because they described the Ontario context and therefore help in interpreting the indicators. This section provides a snapshot of the need, use and supply of health care services for mental health in Ontario. • Primary and Specialty Outpatient Care. Section everyday living and to improve their quality of life, by 5B presents indicators of depression care in outpatient addressing factors such as housing, vocational training, settings. Because of data limitations, only care provided peer support and social activities and by helping to by Ontario physicians paid on a fee-for-service basis coordinate services. Primary care and specialty could be measured. outpatient care providers focus on the diagnosis and clinical treatment of depression, while acute and specialty hospital inpatient services provide more intensive care in a structured setting, focusing on people whose condition is unstable or highly dysfunc- Improving Health and Promoting Health Equity in Ontario • Acute and Specialty Inpatient Care. Section 5C measures indicators of depression care provided in inpatient settings and on the transition back to the community. 13 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 We chose the indicators in this chapter to reflect the Plan (OHIP); National Ambulatory Care Reporting overarching objectives set by the Ontario MOHLTC (see System (NACRS); Ontario Drug Benefit (ODB) database; Exhibit 2.3 in the POWER Study Framework, chapter 2). ICES Physician Database (IPDB); ICES Mother-Baby Appendix 5.1 indicates which of the Ontario Health Linked database (MOMBABY) and Statistics Canada Quality Council’s nine attributes of a high performing 2001 Census. A complete list of the indicators reported health system each indicator assesses and also which of in this chapter and their data sources can be found in the strategic objectives included in the Ontario MOHLTC Appendix 5.2. strategy map would be met through improvement on each indicator. All indicators are reported at the provincial level and at the Local Health Integration Network (LHIN) level We used multiple data sources in this report including when sample size allowed. All analyses were stratified the Canadian Community Health Survey (CCHS), Cycle by sex (where applicable) and then by income, age or 1.1 (2000/01); Daily Census Summary Report Mental rural/urban residency. Age-adjustment was done using Health Beds online, MOHLTC Health Data Branch; indirect standardization. Appendix 5.3 provides a brief Canadian Institute for Health Information Discharge description of the research methods. Abstract Database (CIHI-DAD); Ontario Health Insurance Measuring Depression In this chapter, we used population survey data and series of questions is used to calculate the predicted health administrative data to discover whether there probability of major depressive episodes occurring were sex disparities or other disparities in the treatment within the year preceding the interview.57 Respondents of depression in Ontario. Since these data were not whose predicted probability score was 0.9 or greater specifically created to answer our questions and also were considered to have probable depression. However, because they gathered different kinds of information, this scale was never fully validated, so rates reported we had to use different definitions for depression here may differ from actual population prevalence (see depending on which data were used. Appendix 5.3 for more detail). According to the Diagnostic and Statistical Manual Physician visit for depression, hospital Version IV (DSM-IV), a major depressive episode is a period of two weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by symptoms such as decreased energy, changes in sleep and appetite, impaired concentration and feelings of guilt, hopelessness or suicidal thoughts. For this chapter, we used the following definitions: system to tell us how many people had a physician visit for depression or a hospital stay for depression. Physician visits for depression included visits with an OHIP diagnostic code for depression (311) or reactive defined as hospitalizations where the most responsible diagnosis was an ICD-10 code for major depression (see The Canadian Community Health Survey (CCHS), Cycle 1.1 uses the Composite International Diagnostic 14 We used data routinely collected by the health care depression (300). Hospital stays for depression were Probable depression: Interview-Short Form for Major Depression. This stay (hospitalization) for depression: Appendix 5.2 and Appendix 5.3 for more detail on the data sources and definitions). Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | List of Exhibits List of Exhibits Section 5A Background Measures—the Need, Use and Supply Exhibit 5A.10 Summary of rural/urban residency differences (rural-to-urban ratios and 95% confidence intervals) in background measures of need for and use of depression care, by sex, in Ontario..........................34 Exhibit 5A.1 Age-standardized prevalence of probable depression in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2000/01................. 23 Exhibit 5A.11 Numbers of GP/FPs and psychiatrists per 100,000 population aged 15 and older, by physician type and Local Health Integration Network (LHIN), in Ontario, 2005/06........................................................ 36 Exhibit 5A.2 Prevalence of probable depression in Ontarians aged 15 and older, by Local Health Integration Network (LHIN), 2000/01..........................24 Exhibit 5A.12 Number of psychiatric beds per 100,000 population aged 15 and older, by Local Health Integration Network (LHIN), in Ontario, 2005/06....... 37 Exhibit 5A.3 Sex differences (women-to-men ratios and 95% confidence intervals) in measures of self-reported health and functioning among individuals with probable depression, in Ontario, 2000/01..................................26 Exhibit 5A.13 Treatment rates and costs associated with depression and core mental health care use in Ontarians aged 15 and older, by measure and Local Health Integration Network (LHIN), 2005/06...............38 of Health Care Services for Mental Health Exhibit 5A.4 Age-standardized rate (per 100,000 population) of hospitalizations for depression in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2005/06...................27 Exhibit 5A.5 Age-standardized percentage of Ontarians aged 15 and older who had an Ontario Health Insurance Plan (OHIP) core mental health visit, by sex and neighbourhood income quintile, 2005/06............29 Exhibit 5A.6 Age-standardized Ontario Health Insurance Plan (OHIP) core mental health care costs per capita, by sex and neighbourhood income quintile, in Ontario, 2005/06....................................................30 Exhibit 5A.7 Age-standardized rate (per 100,000 population) of electroconvulsive therapy (ECT) users in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2005/06................. 31 Exhibit 5A.8 Summary of sex differences (womento-men ratios and 95% confidence intervals) in background measures of need for and use of depression care, in Ontario.......................................32 Exhibit 5A.9 Summary of neighbourhood income differences (lowest-to-highest neighbourhood income quintile ratios and 95% confidence intervals) in background measures of need for and use of depression care, in Ontario.......................................33 Improving Health and Promoting Health Equity in Ontario Section 5B Primary and Specialty Outpatient Care Exhibit 5B.1 Age-standardized percentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and annual household income, 2000/01.......................................43 Exhibit 5B.2 Percentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and age group, 2000/01.....43 Exhibit 5B.3 Age-standardized percentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and rural/urban residency, 2000/01.....................................................44 Exhibit 5B.4 Age-standardized percentage of adults aged 66 and older, starting a new course of antidepressants who had three or more physician visits for depression within 12 weeks of starting medication, by sex and neighbourhood income quintile, in Ontario, 2005/06......................................46 Exhibit 5B.5 Percentage of adults aged 66 and older, starting a new course of antidepressants who had three or more physician visits for depression within 12 weeks of starting medication, by sex and age group, in Ontario, 2005/06........................................................47 15 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Exhibit 5B.6 Percentage of adults aged 66 and older, starting a new course of antidepressants who had three or more physician visits for depression within 12 weeks of starting medication, by Local Health Integration Network (LHIN), in Ontario, 2005/06..........................48 Exhibit 5B.7 Age-standardized percentage of women who had a physician visit for depression within one year of giving birth by neighbourhood income quintile, in Ontario, 2005/06........................................................49 Section 5C Acute and Specialty Inpatient Care Exhibit 5C.1 Age-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and neighbourhood income quintile, in Ontario, 2005/06..................................... 54 Exhibit 5C.2 Age-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and rural/urban residency, in Ontario, 2005/06........................................................55 Exhibit 5C.3 Percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by Local Health Integration Network (LHIN), in Ontario, 2005/06....................................................56 Exhibit 5C.4 Age-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06 ........................ 57 Exhibit 5C.5 Percentage of patients aged 15 and older who had a post-discharge physician visit for depression, by sex and time from discharge, 2005/06....................58 Exhibit 5C.6 Mean number of days to a first physician visit for depression in patients aged 15 and older admitted to hospital for depression, by sex and neighbourhood income quintile, in Ontario, 2005/06........................................................59 16 Exhibit 5C.7 Mean number of days to a first physician visit for depression in patients aged 15 and older admitted to hospital for depression, by sex and age group, in Ontario, 2005/06 ...................................... 60 Exhibit 5C.8 Age-standardized percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and neighbourhood income quintile, in Ontario, 2005/06....................................61 Exhibit 5C.9 Percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and age group, in Ontario, 2005/06...................62 Exhibit 5C.10 Percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by Local Health Integration Network (LHIN), in Ontario, 2005/06.........63 Exhibit 5C.11 Age-standardized percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06 ..................................................... 64 Exhibit 5C.12 Age-standardized 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by sex and neighbourhood income quintile, in Ontario, 2005/06..... 65 Exhibit 5C.13 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by Local Health Integration Network (LHIN), in Ontario, 2005/06 ........................ 66 Exhibit 5C.14 Age-standardized 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06.....................................................67 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | List of Exhibits © www.istockphoto.com Improving Health and Promoting Health Equity in Ontario 17 A Guide to Reading Maps Maps are the main visual representation of spatial patterns of data and analyses covered in this Report. Ontario is difficult to map as a province, due to its The main feature to look for is the height of the bars, vast areas in the North and detailed characteristics in since it represents the value of the mapped attribute. The the South. As such, all maps consist of three views— larger the attribute number (relative risk, odds ratio or Northern Ontario, Toronto and surrounding areas, and rate), the taller the bar. The number at the top or beside Southern Ontario. The measures of distance and area on each bar represents the actual value of the attribute. these views differ from one another. If the attribute is presented in two subgroups (e.g., There are two types of thematic maps in this Report that women and men) as in Figure 2, then each LHIN area on depict a magnitude of analyzed variables: 1) bar chart the map has two bars. When the attribute is presented maps and 2) choropleth (shaded) maps. The following in four subgroups (e.g., lower-education women, higher- descriptions aim to help the reader correctly view and education women, lower-education men, and higher- interpret these two map types. education men) as in Figure 3, then each LHIN area on the map has four bars. In all cases, the height of the bar Bar Chart Maps is proportional to the value of the mapped attribute. Bar chart maps can depict a variety of numeric variables In the legend of the map the top set of bars reflects the including counts and ratios across Local Health highest observed value in the depicted data set. This can Integration Networks (LHINs) in Ontario. In most of the be used for visual comparison with the bars on the map. maps in this Report, the bars show values of relative risks, odds ratios or rates (percentages). The bottom set of bars shows the overall Ontario values of the depicted attributes and can be also compared visually to the bars on the map. Figure 2: Example of a Two Bar Map Northern Ontario H U D S O N Figure 3: Example of a Four Bar Map B 38 13 16 14 Overall Ontario L A K E N I P I G O N In Ontario, 34% of lower-income women, 25% of Thunder Bay 30% of lower-income men higher-income women, and 23% of higher-income men reported having Nactivity limitations. E S U P E R I O K R L A 0 30 34% 18 500 Km 28* 26 Thunder Bay 25% 23% ¥Activities at home, school or work that have been limited due to a long-term physical condition, mental condition or health problem Toronto and surrounding areas 13 43 34 L A K E N I P I G O N 30% Note: See Appendix 3.3 for definitions of annual household income categories 250 36 23 Sudbury me categories A 14 32 18% B Y 28 H U D S O N Northern Ontario A Y % ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 K E L A N 24 24 S U P E R I O R Sudbury 0 250 500 Km Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Reading Maps Overall Ontario L A K E N I P I G O N Choropleth (shaded) maps Frutiger 65 bold. Thunder Bay Choropleth maps use different shades or 17% colours to proportional to a larger data value—the larger the depict data values. Each colour generally represents R I K O shade or colour on the map. data value, theL Adarker the R E S U P E Sudbury Shaded maps usually represent rate or ratio variables set inof Frutiger 55 Roman a Notes range values, as shown in the map legend. In 0 general, the darkness of the shade or colour is 250 Km rather than 500 raw counts or amounts. *extra note line set in Frutiger 55 Roman Figure 4: Example of a Choropleth Map 13 11 Ottawa 9 12 Barrie L 2 A Peterborough 5 3 8 K Markham Kingston Southern Ontario E e Orangeville R O N H U 6 Kitchener 7 Toronto Mississauga K E L A O N T A R I O 0 50 100 Km Hamilton 1 4 London Windsor 10 K E L A 30-day mortality rate (%) 11-12 13-14 15-16 17-18 19-20 E R I E Improving Health and Promoting Health Equity in Ontario 19 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 © www.istockphoto.com 20 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A Section 5A Background Measures—the Need, Use and Supply of Health Care Services for Mental Health Introduction This section provides a snapshot of the need for and use of health care services for mental health in Ontario. In an equitable world with limitless resources, use of health services would match need regardless of factors such as sex, income and geography. This section gives the broad context necessary to Although the data are from different sources and were understand and interpret indicators of depression care gathered at different times for different purposes, they described later in this chapter. show remarkable consistency.28, 61, 62 We have divided We looked at need (including the prevalence of depression and the health and functional status of people living with it), use of services (including physician visits, hospitalizations, treatments received and cost) and supply of medical services (including financial and human resources) for depression and mental health care. Some of these measures focus specifically on depression and depression care. Others, such as the supply and cost measures, relate to mental health in general and were based on definitions used in previous Ontario reports.58-60 The prevalence of depression varies by gender and socioeconomic status as do barriers to accessing them into four subsections: Measures of Need: Prevalence, Health and Functional Status • Prevalence of probable depression • Among people with probable depression: – The percentage who rated their health as fair or poor – The percentage who reported no other comorbid chronic medical conditions – The average number of days in the past two weeks out of bed for all or most of the day – The average number of days in the past two weeks without cutting down on normal activities services for depression care and patterns of use.8-11 Measures of Use: Treatment and Cost The supply of services such as the number of primary • Number of individuals using OHIP core mental health care physicians, psychiatrists and hospital beds per capita vary across communities.58 These factors all contribute to the cost of depression care. services per 100,000 population • OHIP core mental health services costs per capita • Hospitalization rates for depression per 100,000 population Improving Health and Promoting Health Equity in Ontario 21 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 • Number of individuals who received electroconvulsive therapy (ECT) per 100,000 population • Number of psychiatrists per 100,000 population • Number of acute hospital psychiatric beds per 100,000 population Measures of Supply: Financial and Human Resources • Number of general practitioners (GPs) or family practice physicians (FPs) per 100,000 population Patterns of Need, Use and Supply • Geographic patterns of use were examined with the goal of comparing them to the patterns of need and supply Interpreting Risk Ratios In this section we present a number of risk ratio figures. interval from 0.5 to 1.5 contains 1.0), this is interpreted Risk ratios estimate the likelihood that an event (e.g., as the two groups not being different in terms of their having probable depression) occurring in one group is likelihood of having the event. the same or different from the likelihood of the event occurring for another group. A ratio of 1.0 indicates that the likelihood for the two groups is equal (or very close to equal). A ratio that is less than 1.0 (e.g., 0.5) indicates that the likelihood is lower for the first group compared to the second, while a ratio greater than For example in Exhibit 5A.8 the risk ratio for probable depression in women compared to men is 1.98. This means that women are 1.98 times (or twice) as likely to have probable depression as men. The 95% confidence interval is (1.74, 2.24). This means that taking into account variation due to sampling, we can have 95% 1.0 indicates that it is higher. For each risk ratio, we also provide 95% confidence intervals to estimate the uncertainty associated with the ratio. If the value of 1.0 occurs within a confidence interval (e.g., a confidence certainty that the true value lies within this range. Because the lower value is greater than one, we can say that women have a higher prevalence of probable depression than men. 1.98 Prevalence of probable depression (percentage)^ 0.5 1.0 1.5 2.0 2.5 POWER Study 22 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A EXHIBITS AND FINDINGS Measure of need: Prevalence of probable depression Measure: This measure assesses the percentage of Ontarians aged 15 and older with probable depression in 2000/01. Background: Worldwide, major depression is a leading cause of disability and the third leading cause of burden of disease as measured in disability-adjusted life years (DALYS—the years of potential life lost because of early death, plus the years of productive life lost because of the disability).63 Mood disorders (of which depression is the most common) have a major economic impact because of both health care costs and lost productivity. Because they are so common, cause suffering, pose a risk of suicide, reduce quality of life and have a large impact on the economy, mood disorders are a serious public health concern in Canada. This measure is based on data from the Canadian Community Health Survey (CCHS), Cycle 1.1 which measures depression using the Composite International Diagnostic Interview-Short Form (CIDI-SF) for Major Depression. This series of questions is used to calculate the predicted probability of major depressive episodes occurring within the year preceding the interview.57 Respondents whose predicted probability score was 0.9 or greater were considered to have probable depression. However, this scale was never fully validated, so rates reported here may differ from actual population prevalence. Findings: In Ontario, in 2000/01, 7.4 percent of people aged 15 and older met the criteria for having probable depression. Women were more likely than men to have probable depression (9.8 percent versus 4.9 percent, respectively). EXHIBIT 5A.1 | A ge-standardized prevalence of probable depression in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2000/01 FINDINGS •The prevalence of depression varied by income for women and men. Rates were highest among those living in the lowestincome neighbourhoods (11.8 percent of women and 5.5 percent of men) compared to those living in the highest-income neighbourhoods (8.5 percent of women and 4.2 percent of men). •The income difference in the prevalence of probable depression was significant for women but not for men. Percentage (%) •Women were twice as likely as men to have probable depression, regardless of neighbourhood income. 25 20 15 11.8 10.5 10 5 0 5.5 Q1 (lowest) 9.5 8.9 5.4 Q2 4.4 Q3 8.5 5.0 Q4 4.2 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1; Statistics Canada 2001 Census Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 23 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5A.2 | P revalence of probable depression in Ontarians^ aged 15 and older, by Local Health Integration Network (LHIN), 2000/01 FINDINGS •Sex differences in the prevalence of probable depression at the LHIN level were not reported because of small sample sizes in a number of LHINs. In those LHINs with adequate sample sizes, twice as many women as men had probable depression, consistent with the overall provincial pattern. •After adjusting for age, prevalence of depression remained quite similar to the unadjusted rates, ranging from 5.1 percent in the Central East LHIN to 9.2 percent in the Toronto Central LHIN. The pattern across LHINs also did not change after adjusting for age (data not shown). Percentage (%) •There was significant regional variation in the prevalence of depression, from a low of 5.2 percent in the Central East LHIN to 9.3 percent in the Toronto Central LHIN. 25 20 15 10 7.2 6.5 1 2 8.9 8.4 5 0 8.7 9.3 5.8 3 4 5 6 7 6.0 5.2 8 9 7.4 7.9 8.0 8.2 10 12 13 11 7.0 14 Local Health Integration Network (LHIN) 1. Erie St. Clair 8. Central 2. South West 9. Central East 3. Waterloo Wellington 4. Hamilton Niagara Haldimand Brant 10. South East 11. Champlain 5. Central West 12. North Simcoe Muskoka 6. Mississauga Halton 13. North East 7. Toronto Central 14. North West Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1 ^ Brant region did not participate in the depression module of CCHS, Cycle 1.1 POWER Study 24 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A MEASUREs OF NEED: Health and Functional Status Measures: The following measures assess the health and functional status of Ontarians aged 15 and older with probable depression: • The percentage who rated their health as fair or poor • The percentage who reported no other comorbid chronic medical conditions • The average number of days in the past two weeks out of bed for all or most of the day—that is not confined to bed due to illness, injury or hospitalization • The average number of days in the past two weeks without cutting down on normal activities due to illness or injury. Background: Prevalence rates provide information about only one dimension of need.64 Need is also influenced by a person’s general health, the severity of her/his functional impairment and any other health problems or comorbidities. Many people who have depression also have other comorbid chronic medical conditions. These coexisting illnesses or comorbidities may influence treatment choice and outcomes of depression care. Conversely, untreated depression can lead to worse outcomes for comorbid chronic medical conditions. The number of days a person with depression does not remain in bed or does not need to cut down on their normal activities is a measure of how well they are able to function. Findings: Among individuals with probable depression in Ontario: • 29 percent reported their health as fair or poor (27 percent of women and 32 percent of men), compared to 13 percent of women and men aged 25 and older in the general population (see Burden of Illness, chapter 3). • 67 percent reported that they had at least one comorbid chronic medical condition in addition to depression (69 percent of women and 62 percent of men); in other words, only 33 percent reported having no comorbid chronic medical conditions. • The average number of days in the previous two weeks when they were out of bed was 13 (13 days for both women and men). • The average number of days in the previous two weeks when they did not have to cut down on normally activities was 12 (12 days in women and 13 days in men). Improving Health and Promoting Health Equity in Ontario 25 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5A.3 | S ex differences (women-to-men ratios and 95% confidence intervals) in measures of self-reported health and functioning among individuals with probable depression, in Ontario, 2000/01 0.87 Percentage rating own health as fair or poor 0.81 Percentage with no other comorbid chronic medical conditions 1.00 Average number of days out of bed in past two weeks 0.99 Average number of days without cutting down on normal activities in past two weeks 0.5 1.0 1.5 2.0 Women-to-men ratio Data SOURCE: Canadian Community Health Survey (CCHS), Cycle 1.1 Note: See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A FINDINGS •Women with probable depression were significantly less likely than men to report having no other comorbid chronic medical conditions. •There were no differences between women and men with probable depression in how they rated their own health or ability to function. •Among people with probable depression, health and functional status did not vary by neighbourhood income or Local Health Integration Network (LHIN) (data not shown). POWER Study 26 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A Measure of Use: Rate of hospitalization for depression Measure: This descriptive measure reports the number of hospitalizations for depression per 100,000 population aged 15 and older. Background: Although most individuals with mood disorders (including depression) are treated in the community, hospitalization is sometimes necessary. Serious depressions may require hospitalization, with follow up medical attention or monitoring. High rates of hospitalization may signal a problem in how mental health services are delivered and integrated—good community care can prevent hospitalization. Ontario’s policy for the past three decades has been to provide care in the least restrictive setting65 with inpatient care being part of a network of physician, community and social support services that aim to keep patients in the community. Findings: In Ontario, the rate of hospitalization for depression for the period from March 1, 2005 to February 28, 2006 was 108 per 100,000 population aged 15 and older: 127 per 100,000 women and 87 per 100,000 men. EXHIBIT 5A.4 | A ge-standardized rate (per 100,000 population) of hospitalizations for depression in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2005/06^ FINDINGS •Lower-income women and men were more likely to be hospitalized for depression, with the rate in the lowest-income quintile nearly twice the rate for the highest-income quintile (178 versus 97 per 100,000 for women; 124 versus 68 per 100,000 for men). Rate per 100,000 •Women had higher rates of hospitalization than men, regardless of neighbourhood income. 200 150 178 148 124 122 105 98 100 76 97 71 68 50 0 Q1 (lowest) Q2 Q3 Q4 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Statistics Canada 2001 Census; Registered Persons Database (RPDB) ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 27 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 MEASURES OF USE: Ontario Health Insurance Plan (OHIP) core mental health care users and OHIP core mental health care costs per capita Measures: Two measures were used to assess the use of OHIP core mental health services: • The proportion of Ontarians aged 15 and older who used OHIP physician services for mental health (assessment, diagnosis or treatment) • The average cost (in 2005 Canadian dollar equivalents (CAD)) per capita paid for these core mental health services Background: Household surveys in Canada and Ontario consistently report that the majority of mental health care reported by survey respondents has been received from general practitioners and family physicians with the next largest source of care being psychiatrists (of people who use mental health services, approximately 60-75 percent receive care from general practitioners and approximately 25-40 percent receive care from psychiatrists).11, 66, 67 This fits with the view of the family doctor as the gatekeeper of the health care system where access to specialist care is by referral and all care is coordinated through a frontline provider. In Ontario, the most complete data source for both general and specialty physician care is the OHIP claims database. Findings: In Ontario, 15 percent of the population aged 15 and older used OHIP core mental health services including psychiatric assessment, diagnosis or treatment in the course of one year (18 percent of women and 11 percent of men). The average cost paid for these services was $33 (CAD) per capita ($41 (CAD) for women and $24 (CAD) for men). 28 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A EXHIBIT 5A.5 | A ge-standardized percentage of Ontarians aged 15 and older who had an Ontario Health Insurance Plan (OHIP) core mental health visit,^ by sex and neighbourhood income quintile, 2005/06† FINDINGS •Low-income women and men were somewhat more likely to use core mental health services; however, these differences were very small. 50 Percentage (%) •Almost twice as many women as men used OHIP core mental health services, regardless of neighbourhood income. 40 30 20 19 10 0 18 18 12 Q1 (lowest) 11 Q2 18 11 Q3 18 10 Q4 10 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census; Registered Persons Database (RPDB) ^ Based on fee-for-service OHIP billings for assessment, diagnosis or treatment † People who accessed services from Mar 1, 2005 - Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 29 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 FINDINGS •Consistent with their higher rates of physician visits for OHIP core mental health services, women also incurred higher OHIP core mental health care costs per capita than men, regardless of neighbourhood income. Cost per capita (CAD) EXHIBIT 5A.6 | A ge-standardized Ontario Health Insurance Plan (OHIP) core mental health care costs^ per capita, by sex and neighbourhood income quintile, in Ontario, 2005/06† 100 •OHIP costs for core mental health services varied by neighbourhood income. Women and men living in the highest-income neighbourhoods had significantly higher OHIP costs than individuals living in lowerincome neighbourhoods. 80 60 40 40 40 25 20 0 Q1 (lowest) 48 39 23 Q2 39 22 Q3 29 22 Q4 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census; Registered Persons Database (RPDB) ^ Based on fee-for-service OHIP billings for assessment, diagnosis or treatment † People who accessed services from Mar 1, 2005 - Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study 30 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A MEASURE OF USE: Electroconvulsive therapy (ECT) use Measure: This measure reports the number of electroconvulsive therapy (ECT) users per 100,000 population aged 15 and older. Background: Electroconvulsive therapy has been found to be effective for individuals with severe and treatmentresistant forms of depression.68, 69 It is also used to treat other severe mental illnesses such as bipolar disorder and schizophrenia, but more as an alternative to first-line treatment options.69 Findings: In Ontario, the number of ECT users was 15 people per 100,000 population aged 15 and older. The rate was significantly higher in women than in men: 18 per 100,000 versus 11 per 100,000, respectively. EXHIBIT 5A.7 | A ge-standardized rate (per 100,000 population) of electroconvulsive therapy (ECT) users in Ontarians aged 15 and older, by sex and neighbourhood income quintile, 2005/06^ FINDINGS •Women living in lower-income neighbourhoods were somewhat more likely to receive ECT than those living in higher-income neighbourhoods. Rate per 100,000 •Women were more likely than men to receive ECT, regardless of neighbourhood income quintile. 50 40 30 20 20 20 12 13 16 9 10 0 Q1 (lowest) Q2 16 Q3 17 12 Q4 11 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census; Registered Persons Database (RPDB) ^ People who accessed services from Mar 1, 2005 - Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 31 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5A.8 | S ummary of sex differences (women-to-men ratios and 95% confidence intervals) in background measures of need for and use of depression care, in Ontario 1.98 Prevalence of probable depression (percentage)^ 1.45 Rate of hospitalization for depression per 100,000† 1.69 OHIP core mental health service users (percentage)¥‡ 1.70 OHIP core mental health costs per capita (CAD)¥‡ 1.61 Electroconvulsive therapy users per 100,000¥ 0.5 1.0 1.5 Women-to-men ratio 2.0 2.5 Data sources: ^Canadian Community Health Survey (CCHS), Cycle 1.1, 2000/01 †Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006; Registered Persons Database (RPDB) ¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006; RPDB ‡Extremely narrow confidence intervals Note: See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A FINDINGS •Women were almost twice as likely as men (risk ratio - 1.98) to have probable depression. •The pattern of service use was similar to the prevalence pattern. Women were consistently and significantly more likely than men to use both OHIP core mental health services and those more specific to the care of depression (hospitalization for depression and ECT use). POWER Study 32 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A EXHIBIT 5A.9 | S ummary of neighbourhood income differences (lowest-to-highest neighbourhood income quintile ratios and 95% confidence intervals) in background measures of need for and use of depression care, in Ontario 1.36 Prevalence of probable depression (percentage)^ 1.83 Rate of hospitalization for depression per 100,000† 1.09 OHIP core mental health service users (percentage)¥‡ OHIP core mental health costs per capita (CAD)¥‡ 0.85 1.16 Electroconvulsive therapy users per 100,000¥ 0.5 1.0 1.5 2.0 2.5 Lowest-to-highest neighbourhood income ratio Data sources: Statistics Canada 2001 Census ^Canadian Community Health Survey (CCHS), Cycle 1.1, 2000/01 †Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006; Registered Persons Database (RPDB) ¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006; RPDB ‡Extremely narrow confidence intervals Notes: See Appendix 5.3 for details about neighbourhood income quintile calculation See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A FINDINGS •Lowest-income neighbourhoods had a significantly higher prevalence of probable depression than highest-income neighbourhoods (risk ratio - 1.36). •Women and men living in the lowest-income neighbourhoods were also somewhat more likely to use OHIP core mental health services and to receive ECT and much more likely to be hospitalized for depression. •However, individuals living in the lowest-income neighbourhoods accounted for lower OHIP core mental health care costs, which suggests they either made fewer visits or received less expensive services than those living in the highest-income neighbourhoods. •The effect of neighbourhood income was similar for women and men for use and cost measures of depression care (data not shown). POWER Study Improving Health and Promoting Health Equity in Ontario 33 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5A.10 | S ummary of rural/urban residency differences (rural-to-urban ratios and 95% confidence intervals) in background measures of need for and use of depression care, by sex, in Ontario 0.93 Prevalence of probable depression (percentage)^ 0.85 1.29 Rate of hospitalization for depression per 100,000† 1.44 0.91 OHIP core mental health services users (percentage)¥ 0.83 0.60 OHIP core mental health costs per capita (CAD)¥ 0.56 0.80 Electroconvulsive therapy users per capita 100,000¥ 0.81 0.5 1.0 1.5 2.0 2.5 Rural-to-urban ratio Women Men Data sources: Statistics Canada 2001 Census ^Canadian Community Health Survey (CCHS), Cycle 1.1, 2000/01 †Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006 ¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006 ‡Extremely narrow confidence intervals Notes: See Appendix 5.3 for details about rural/urban residency calculation See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A FINDINGS •The prevalence of probable depression was similar in rural and urban regions. •Women and men from rural areas were less likely to have had OHIP core mental health visits but were more likely to have been hospitalized for depression than those living in urban areas. •Women and men from rural areas also incurred lower OHIP core mental health costs per capita. POWER Study 34 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A MEASURES OF SUPPLY: FINANCIAL AND HUMAN RESOURCES Measures: Three measures of supply of medical services for mental health care are explored: • Number of general practitioners (GPs) or family practice physicians (FPs) per 100,000 population • Number of psychiatrists per 100,000 population • Number of acute hospital psychiatric beds per 100,000 population Background: Most Canadians receive their medical mental health care through visits to family physicians and psychiatrists.11, 66, 67 A much smaller percentage receive care in walk-in clinics, community mental health agencies, case management and crisis teams, emergency departments and inpatient hospital beds.70 The three supply measures reported here measure the most frequently visited medical providers of mental health care (family physicians and psychiatrists) and the most costly service (hospital beds). Findings: In Ontario, there are 105 GP/FPs, 19 psychiatrists and 51 acute hospital psychiatric beds per 100,000 population. Improving Health and Promoting Health Equity in Ontario 35 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Physicians per 100,000 EXHIBIT 5A.11 | N umbers of GP/FPs^ and psychiatrists per 100,000 population aged 15 and older, by physician type and Local Health Integration Network (LHIN), in Ontario, 2005/06 200 168 150 100 102 93 90 98 90 75 72 0 1 17 2 GP/FPs 9 3 14 4 6 5 12 10 6 7 113 102 83 72 50 7 140 135 120 8 21 8 9 10 30 9 11 12 10 13 10 14 Psychiatrists Local Health Integration Network (LHIN) 1. Erie St. Clair 6. Mississauga Halton 11. Champlain 2. South West 7. Toronto Central 12. North Simcoe Muskoka 3. Waterloo Wellington 8. Central 13. North East 4. Hamilton Niagara Haldimand Brant 9. Central East 14. North West 5. Central West 10. South East Data sources: ICES Physician Database (IPDB); Registered Persons Database (RPDB) ^ GP/FP=General Practitioner/Family Physician FINDINGS •There was considerable regional variation in physician supply across Ontario. •The Toronto Central LHIN had more than twice as many GP/FPs as the Erie St. Clair LHIN (168 per 100,000 versus 72 per 100,000). •The Toronto Central LHIN had more than twelve times as many psychiatrists available as the Central West LHIN (72 per 100,000 versus 6 per 100,000). POWER Study 36 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A EXHIBIT 5A.12 | N umber of psychiatric beds per 100,000 population aged 15 and older, by Local Health Integration Network (LHIN), in Ontario, 2005/06 FINDINGS Beds per 100,000 •There was nearly a three-fold difference in the number of psychiatric beds available across the LHINs. The Champlain LHIN had 35 beds per 100,000 population compared to 10 beds per 100,000 in the Waterloo Wellington LHIN. 50 40 35 28 30 20 0 27 21 17 10 10 1 2 34 3 4 14 5 26 17 12 11 6 7 8 9 16 15 10 11 12 13 14 Local Health Integration Network (LHIN) 1. Erie St. Clair 2. South West 8. Central 9. Central East 3. Waterloo Wellington 4. Hamilton Niagara Haldimand Brant 10. South East 11. Champlain 5. Central West 12. North Simcoe Muskoka 6. Mississauga Halton 13. North East 7. Toronto Central 14. North West Data sources: Daily Census Summary Report Mental Health Beds online, MOHLTC Health Data Branch (http://www.mohltcfim.com/cms/ client_webmaster/index.jsp, accessed February 6, 2008); Registered Persons Database (RPDB) POWER Study Improving Health and Promoting Health Equity in Ontario 37 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Patterns of need, use and supply The geographic variations in three of the descriptive measures of use are presented together with the objective of comparing them to the geographic patterns of need and supply presented earlier in this section. 80 Rate per 100,000 300 70 250 60 200 50 40 150 30 100 20 50 0 10 1 2 3 4 5 6 † Rate of hospitalization for depression OHIP core mental health costs¥ 7 8 9 10 11 12 13 Costs per capita (CAD) EXHIBIT 5A.13 | T reatment rates and costs associated with depression and core mental health care use in Ontarians aged 15 and older, by measure and Local Health Integration Network (LHIN), 2005/06^ 14 ECT users ¥ Local Health Integration Network (LHIN) 1. Erie St. Clair 6. Mississauga Halton 11. Champlain 2. South West 7. Toronto Central 12. North Simcoe Muskoka 3. Waterloo Wellington 8. Central 13. North East 9. Central East 14. North West 4. Hamilton Niagara Haldimand Brant 5. Central West 10. South East Data sources: Registered Persons Database (RPDB) †Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) ¥Ontario Health Insurance Plan (OHIP) ^People who were discharged from hospital or accessed services from Mar 1, 2005 - Feb 28, 2006 FINDINGS •The geographic patterns of hospitalizations for depression, electroconvulsive therapy use and cost per capita for Ontario Health Insurance Plan (OHIP) core mental health services varied considerably and there was no consistent relationship among these patterns. Some areas with low rates of hospitalization had high per capita expenditures for core mental health care, others did not. •The OHIP core mental health care costs per capita align with the supply of physicians shown in an earlier exhibit (Exhibit 5A.11) while hospitalization rates align with the supply of hospital beds (Exhibit 5A.12). •However, there was no consistent relationship across the LHINs between OHIP core mental health care costs or hospitalization rates and the prevalence of probable depression (Exhibit 5A.2). POWER Study 38 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5A Section 5A Summary of Findings These measures provide a complex backdrop for studying Use gender and sociodemographic inequities in need and • There were distinct sex differences in use of services for access to mental health care. We found, consistent with depression. Women were between one and a half to the literature, that prevalence of probable depression two times more likely than men to use OHIP core mental varied among population subgroups. Women had a health services—a pattern consistent with their higher higher prevalence of depression than men and women rates of depression. living in the lowest-income neighbourhoods had a higher prevalence than women living in the highest-income neighbourhoods. Women with probable depression were more likely to report comorbid chronic medical conditions than men. The data on use of Ontario Health Insurance Plan (OHIP) core mental health services clearly show differences in access by sex, neighbourhood income and rural/urban residency. There was sizable regional variation in supply and use of mental health services. • Although women from lower-income neighbourhoods were more likely to have probable depression than those from higher-income neighbourhoods, they had the same rate of use of OHIP core mental health services. However, women from higher-income neighbourhoods incurred greater OHIP core mental health costs than women from lower-income neighbourhoods. • Women and men from lower-income neighbourhoods were almost twice as likely to be hospitalized for More information on the match between individual need depression but incurred slightly lower average costs for for depression care and OHIP visits for depression follows OHIP mental health services than those from higher- in Sections 5B and 5C of this chapter. income neighbourhoods. Need • Women were twice as likely to have probable depression as men in Ontario. • There were regional and income differences in the • Rural and urban residents used services differently. Rural residents were more likely to be hospitalized for depression, while urban dwellers had higher per capita OHIP costs for mental health care. prevalence of probable depression. Individuals living in Supply the lowest-income neighbourhoods were more likely • Resources such as physician supply and psychiatric to have probable depression than those living in the hospital beds varied markedly across Local Health highest-income neighbourhoods. Integration Networks (LHINs). The differences between • There were no differences in the prevalence of probable the highest and lowest rates per 100,000 population depression between people who were living in rural and among LHINs ranged from twice as many GPs to three urban areas. times as many hospital beds and 12 times as many psy- • Women with probable depression were somewhat more chiatrists. likely to report comorbid chronic medical conditions Patterns of Need, Use and Supply than men. However, there were few differences by sex • Patterns of service use reflected supply more than need. in self-rated health or self-reported functioning among those with probable depression. Improving Health and Promoting Health Equity in Ontario 39 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Section 5B Primary and Specialty Outpatient Care CONTINUUM OF DEPRESSION CARE Prevention/ health promotion Community services/ supports Primary care Specialty outpatient care Acute hospital care Specialty hospital care Introduction Along the continuum of depression care, primary care and specialty outpatient care play a critical role. Primary and specialty outpatient care providers identify and diagnose depression and provide treatment that improves mental health and prevents recurrence of the condition. Early, equitable assessment and treatment are important People with depression often go untreated2-5 and other because the costs of depression are high. Untreated studies suggest that some receive suboptimal care.6, 7 depression results in poor functional status and disability However, there is growing evidence that a number of among women and men with the disease. It can also lead interventions do improve the quality and outcomes of to high costs to the health system and society because depression care.12-14, 72 Furthermore, there are well- suboptimal diagnosis and treatment lead to costly and validated indicators that measure the quality of depression potentially preventable expenses including avoidable care which are in use internationally.73 hospitalizations and lost productivity. In the previous section we showed that women were more likely to be depressed and also more likely to seek medical care for mental health problems. Although the medical literature shows gender differences in how women and men seek help and their reported barriers to care, those issues are In this section we focus on depression care provided in primary and specialty outpatient settings, which are the most frequent source of overall mental health care reported in North American household surveys,74-76 including Ontario surveys.77 beyond the scope of this chapter.71 In this section, we We examined three indicators specific to outpatient look more specifically at the quality of care for depression treatment for depression to assess whether there were in outpatient settings and try to determine whether there gender disparities in depression care; and whether there are sex differences in the delivery of that care. were disparities among women and men associated 40 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5B with income and age in access to or quality of care in care because of some limitations with Ontario Health the province. They are: Insurance Plan (OHIP) data. Only one diagnostic code • Percentage of people with probable depression who had a physician visit for depression • Percentage of patients, aged 66 and older, who filled can be recorded in the OHIP database per patient visit, therefore, a person with depression plus another condition may have her/his visit coded as the other condition instead of depression, leading to under- and continued a new prescription for antidepressant counting. Also, one of the two codes related to depression medication and who had at least three physician visits for (OHIP diagnostic code, 300) combines it with other mental depression in the 12 weeks after starting antidepressants health conditions such as anxiety. Since this is also the • Percentage of women who had given birth who had code most frequently used by family doctors, this leads a physician visit for depression within one year to over-counting of physician visits for depression (see following delivery. Appendix 5.3 for more detail).78 However, when the The definition of a physician visit for depression in this chapter is imprecise and may either under- or overestimate the number of physician visits for depression definition is tied to a person with probable depression or a prescription for an antidepressant, it may more closely indicate a visit where depression was addressed. © www.istockphoto.com Improving Health and Promoting Health Equity in Ontario 41 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBITS AND FINDINGS Percentage of individuals with probable depression who had a physician visit for depression Indicator: This indicator measures the percentage of individuals, aged 15 and older, with probable depression who had a physician visit for depression in the year after being interviewed for a health survey (Canadian Community Health Survey (CCHS), Cycle 1.1). Background: Depression is a treatable condition and high quality care for depression leads to improved patient outcomes. Having a physician visit for depression is often the first step towards receiving this care. The best measures of population need for depression care come from household surveys such as the CCHS, Cycle 1.2 or the World Mental Health 2000 surveys developed by the World Health Organization.79, 80 Studies using these measures find that approximately 50 percent of those who met the survey criteria for major depression in the past year reported no contact with medical mental health services during that time.81, 82 While it is not clear that everyone who meets these kinds of survey criteria requires medically provided depression care, it is still certain that there are many who do not get the treatment they need.77, 83-85 Findings: In Ontario, only 40 percent of people with probable depression (41 percent of women and 37 percent of men) had at least one physician visit for depression within the year following the CCHS interview. 42 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5B EXHIBIT 5B.1 | A ge-standardized percentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and annual household income, 2000/01 FINDINGS 80 Percentage (%) •Low-income women with probable depression were significantly more likely than higher-income women to have had a physician visit for depression. The income variation was not significant in men. 100 60 40 51 41 37 41 44 32 38 33 20 0 Low Lower middle Middle Higher Annual household income Women Men Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1; Ontario Health Insurance Plan (OHIP) Note: See Appendix 5.3 for definitions of annual household income categories POWER Study EXHIBIT 5B.2 | P ercentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and age group, 2000/01 FINDINGS •The rate of physician visits for depression was highest among those aged 45-64 and lowest among those aged 15-24. Percentage (%) •There was no difference in the percentage of women and men who had a physician visit for depression, irrespective of age. 100 80 60 40 43 50 47 38 46 28* 27 26* 20 0 15-24 25-44 45-64 65+ Age group (years) Women Men Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1; Ontario Health Insurance Plan (OHIP) * Interpret with caution due to high sampling variability POWER Study Improving Health and Promoting Health Equity in Ontario 43 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5B.3 | A ge-standardized percentage of Ontarians aged 15 and older with probable depression who had a physician visit for depression, by sex and rural/urban residency, 2000/01 FINDINGS •Among rural residents, women with probable depression were significantly more likely to have a physician visit for depression than men (45 percent versus 33 percent, respectively). There were no sex differences among urban residents. •Across all LHINs, less than 50 percent of those with probable depression had a physician visit for depression within one year. The rates ranged from 31 percent in the North East LHIN to 45 percent in the Central West and Toronto Central LHINs; however this variation was not significant, possibly due to small sample sizes at the LHIN level (data not shown). Percentage (%) •The percentage of individuals with probable depression who had a physician visit for depression did not vary by rural/ urban residency (data not shown). 100 80 60 45 33 41 37 Rural Urban 40 20 0 Rural/urban residency Women Men Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1; Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census Note: See Appendix 5.3 for definitions of rural/urban residency POWER Study 44 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5B PERCENTAGE OF OLDER ADULTS STARTING A NEW COURSE OF ANTIDEPRESSANT MEDICATION WHO RECEIVED ADEQUATE PHYSICIAN FOLLOW UP Indicator: This indicator measures the percentage of patients aged 66 and older, who filled and continued a new prescription for antidepressant medication (i.e., refilled within 100 days) and who had the recommended minimum of at least three physician visits for depression in the 12 weeks after starting antidepressants. Background: This indicator assesses the quality of depression care for people on medication. Antidepressants effectively treat depression in about two-thirds of moderate to severe cases. People vary in their response to both the kind of antidepressant and the dosage because of factors such as genetic makeup, body mass index, racial or ethnic background and physical health. Therefore, frequent evaluation by a physician is important during the first 12 weeks of treatment (the acute phase) to monitor patients’ responses, reduction of symptoms and adverse reactions to the drug.86 It was not possible to look at all adults who started antidepressant medication, because prescription data were only available for those aged 65 and older. Because we restricted our sample to people who had not filled a prescription for antidepressants in the previous year, the sample was limited to people aged 66 and older to be able to confirm this. Findings: In Ontario, 9.6 percent of patients aged 66 and older (9.5 percent of women and 9.9 percent of men) who filled and continued a new prescription for antidepressants had at least three physician visits for depression in the 12 weeks after starting medication. Improving Health and Promoting Health Equity in Ontario 45 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5B.4 | A ge-standardized percentage of adults aged 66 and older, starting a new course of antidepressants^ who had three or more physician visits for depression within 12 weeks of starting medication, by sex and neighbourhood income quintile, in Ontario, 2005/06† FINDINGS •Women and men living in lower-income neighbourhoods were somewhat less likely to have had at least three physician visits for depression after starting on antidepressants than those living in higherincome neighbourhoods. This difference was not significant among men, possibly due to small sample size. Percentage (%) •There was no difference in the percentage of women and men aged 66 and older who had at least three physician visits for depression after starting on antidepressants, irrespective of neighbourhood income. 25 20 15 10 8.7 9.3 9.6 9.1 9.5 10.0 9.7 9.8 Q1 (lowest) Q2 Q3 Q4 10.7 11.0 5 0 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Ontario Drug Benefits (ODB) database; Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census ^ People with no history of antidepressant use in the past year, who then filled two or more antidepressant prescriptions with a 100-day period †People whose first prescriptions were filled from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study 46 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5B EXHIBIT 5B.5 | P ercentage of adults aged 66 and older, starting a new course of antidepressants^ who had three or more physician visits for depression within 12 weeks of starting medication, by sex and age group, in Ontario, 2005/06† FINDINGS •Women and men were equally disadvantaged, irrespective of age, income or LHIN (income and LHIN data are not shown). Percentage (%) •The percentage of patients who had the recommended number of physician visits to monitor antidepressant use declined significantly with age for women and men. 25 15 11.6 12.0 10.4 10.7 10 7.3 7.1 5 0 66-70 71-80 81+ Age group (years) •This age variation was consistent across most Local Health Integration Networks (LHINs). •Older patients often see their physicians for a complex variety of health problems, so we broadened this indicator to include physician visits for any reason, even though the data did not allow us to assess whether care for depression was actually provided. The more broadly defined version of this indicator showed substantially higher rates for both sexes, ranging between 80 and 90 percent. There were no sex differences for this version of the indicator across age, neighbourhood income, or LHIN (data not shown). 20 Women Men Data sources: Ontario Drug Benefits (ODB) database; Ontario Health Insurance Plan (OHIP) ^ People with no history of antidepressant use in the past year, who then filled two or more antidepressant prescriptions within a 100-day period †People whose first prescriptions were filled from Mar 1, 2005 Feb 28, 2006 •The age variation seen in the broader definition of follow up was the opposite of that found for the narrower definition. The percentage of people who saw their doctors three times in the 12 weeks after they started a new course of antidepressants increased significantly with age, from 80 percent (aged 66-70) to 84 percent (aged 71-80) to 87 percent (aged 81 and older). •As was the case for the narrower definition, the age variation was consistent and significant across most LHINs. POWER Study Improving Health and Promoting Health Equity in Ontario 47 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 In Ontario, 9.6% of individuals, aged 66 and older who started and continued on an antidepressant had at least three physician visits for depression in the 12 weeks after starting medication. H U D S O N H U D S O N B A EXHIBIT 5B.6 | Percentage of adults aged 66 and older, starting a new course of antidepressants^ who had three or more physician visits for depression within 12 weeks of starting medication, by Local Health Integration Network (LHIN), in Ontario, 2005/06† Y A B Y FINDINGS •Unadjusted rates of having had three or more physician visits for depression after starting and continuing on antidepressant medication ranged from 5.9 percent in the North West LHIN to 13.6 percent in the Toronto Central LHIN. •After adjusting for age, these rates remained similar to the In Ontario, 9.6% individuals, aged5.9 66 percent and olderin the North West unadjusted rates,ofranging from who started 9.6% and continued on anaged antidepressant had In Ontario, of individuals, 66 and older LHIN to 13.5 percent invisits thefor Toronto Central LHIN. Furthermore, atwho leaststarted three physician depression in the had and continued on an antidepressant the12pattern across LHINs did not change (data not shown). weeks after starting medication. L A K E N I P I G O N L A K E N I P I G O N K E L A at least three physician visits for depression in the 12 weeks after starting medication. R S U P E R I O K E L A •For the broader definition of physician follow up, unadjusted rates ranged from 76 percent in the North West LHIN to 88 percent in the Central LHIN (data not shown). POWER Study S U P E R I O R E Local Health Integration Networks (LHINs) 1 Erie St. Clair 4 Hamilton Niagara Haldimand Brant 2 South West L A 5 Central West 3 Waterloo K Wellington 6 Mississauga Halton 7 Toronto Central 8 Central 9 10 11 12 H U 13 N R O 14 Central East South East Champlain North Simcoe Muskoka North East North West K E L A O † People wh L L E A K L A E A K E R I E K H E RNO RUO UH N T A R I O K E O L A N T A R I O O E K L A N † People whose first prescriptions were filled from Mar 1, 2005 - Feb 28, 2006 L 48 E A K E A K L E R I E E R I E Peoplewith whose first prescriptions were filled 2005who - Feb 28,filled 2006two ^ †People no history of antidepressant use from in theMar past1,year, then or more antidepressant prescriptions with a 100-day period ^ People with no history of antidepressant use in the past year, who then filled two or more antidepressant prescriptions with a 100-day period Data sources: Ontario Drug Benefit Claims (ODB) database; Ontario Health Insurance Plan (OHIP) Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study ^ People wi or more ant Depression | Section 5B Percentage of women who had a physician visit for depression within one year of giving birth Indicator: This indicator measures the percentage of Ontario women who had a physician visit for depression within one year of giving birth in a hospital (excluding still births). Background: Postpartum depression is estimated to occur after 13 percent of births87 although the rate varies across countries and ethnic groups.88, 89 Its impact on the mother, child and family can be substantial, both in the short- and long-term. This indicator provides baseline descriptive information on the proportion of Ontario women who had a physician visit for depression within one year of giving birth. Findings: In Ontario, 20 percent of women who had given birth saw a physician for depression within one year of delivery. EXHIBIT 5B.7 | A ge-standardized percentage of women who had a physician visit for depression within one year of giving birth, by neighbourhood income quintile, in Ontario, 2005/06^ FINDINGS •This indicator varied significantly by age; 20 percent of women aged 25-44 had a physician visit for depression within a year of giving birth compared to 24 percent of women aged 15-24. The rate in the oldest age group (aged 45-64) was less reliable because of small numbers (data not shown). •There was significant regional variation in the percentage of women who gave birth and had a subsequent physician visit for depression within a year, ranging from 15 percent in the North West LHIN to 26 percent in the North Simcoe Muskoka LHIN (data not shown). Percentage (%) •The percentage of women who gave birth and then had a physician visit for depression within one year did not vary by neighbourhood income. 50 40 30 20 21 21 20 20 21 Q1 (lowest) Q2 Q3 Q4 Q5 (highest) 10 0 Neighbourhood income quintile Data sources: ICES Mother-Baby (MOMBABY) Linked Database; Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census ^ Women with in-hospital live births (stillbirths were excluded) who were discharged between Mar 1, 2005 - Feb 28, 2006 note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 49 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Section 5B Summary of FIndings The indicators in this section include three measures with probable depression were the most likely to visit of depression care provided in primary or specialty a physician for depression, although they were not the outpatient settings: age group with the highest prevalence. Among older Ontarians starting antidepressants, age was associated • Care for Ontarians with probable depression; with a decreasing likelihood of physician visits for • Care for older Ontarians starting a new course of depression but an increasing likelihood of physician antidepressant medication and visits for any reason. • Care for postpartum women. Finally, there were differences by income. Women with The first two indicators shared several patterns. We probable depression who had lower annual household found women and men faced no significant differences incomes were more likely have a physician visit for in their access to care. Forty-one percent of women and depression than those with higher annual household 37 percent of men with probable depression had at incomes. However, older women from lower-income least one physician visit for depression within a year of neighbourhoods who started antidepressants were less their survey interview. Older Ontarians who started an- likely to have had the recommended number of follow tidepressant medications had the lowest follow up rates up physician visits than women from higher-income for depression (i.e., at least three physician visits for neighbourhoods. depression within 12 weeks of starting medication); 9.5 The third indicator measured depression care for percent of women and 9.9 percent of men, although postpartum women. The finding that 20 percent of roughly 85 percent had at least three physician visits for Ontario women who gave birth had a physician visit any reason in the important first 12 weeks after starting for depression in the year after delivery was consider- antidepressants. Better data are needed to more ably higher than the rate of postpartum depression accurately assess depression care in outpatient settings. reported in the literature (13 percent).87 One possible We showed potential under-treatment for depression— explanation is the large number of immigrants in 60 percent of Ontarians with probable depression did Ontario. Stewart and colleagues25 found that 35 not have a physician visit for depression care. Because percent of women in Ontario and Quebec who had there is a high potential for impairment of functioning immigrated to Canada less than five years ago scored associated with depression, but a good record of effec- 10 or higher on the Edinburgh Postnatal Depression tiveness for both drug and non-drug therapies, many of Scale, which is the usual cut off score for probable those who do not get care may be suffering needlessly. depression in community samples.88 It is also possible Further, monitoring patients’ responses to drugs and that physicians and some groups of new mothers are their side effects is a critical component of high-quality more aware of the possibility of postpartum depression, care in general, especially for fragile populations such as or that the numbers differed because of the way older adults. physicians use OHIP codes to bill for counselling non- All the indicators showed disparities associated with age although the patterns differed. Ontarians aged 45-64 50 depressed women in some Local Health Integration Networks (LHINs). Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5B © www.istockphoto.com The limitations in our data mean we cannot be depression. The significant differences in postpartum certain why our findings of the rates of physician physician visits for depression across the LHINs (ranging visits for depression during the postpartum period from 15 to 26 percent) suggest local practice patterns were different from other studies. However, because or the way services are organized regionally may there were no significant differences by neighbour- influence rates of physician visits for depression. Other hood income, and younger women were more likely factors that predict postpartum depression, such as than those aged 25-44 to have physician visits for social support or poor marital relationships, may also postpartum depression, it suggests need, as measured play a role87 and could be explored if data on those by prevalence, is not fully reflected in physician visits for issues become available in Ontario. Improving Health and Promoting Health Equity in Ontario 51 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Section 5C Acute and Specialty Inpatient Care CONTINUUM OF DEPRESSION CARE Prevention/ health promotion Community services/ supports Primary care Specialty outpatient care Acute hospital care Specialty hospital care Introduction Acute and specialty hospital care are also vital components of the continuum of depression care. Important services for those with severe depression are provided by emergency departments, inpatient units of acute care hospitals or psychiatric hospitals. The aim of these services is to ameliorate severe It is also important to look at indicators of inpatient care depression symptoms, prevent mortality due to depression because they serve people with the most complex and and stabilize the individual so that she or he can benefit serious forms of depression. These acutely ill patients may from outpatient and other community-based care. be very fragile and at risk of imminent harm to themselves (either due to suicidal intentions or because they are The percentage of people who visit emergency unable to look after their own basic needs) or to others. departments or are hospitalized for depression is quite small: only about 1.5 percent of Ontario’s adult population had emergency department visits for mental Depression of this severity is associated with the highest individual, family and societal burden.95 health reasons.90 Hospitalization rates specifically for The Canadian clinical treatment guidelines for depressive depression are also low, at only 80-150 per 100,000 disorders recommend that discharge from hospital 91 for women and 60-100 per 100,000 for men. services include a discharge plan that refers the patient to Nevertheless, it is important for us to look closely relevant mental health services and monitoring since the at acute and specialty hospital care because these period after discharge is high-risk for suicidal behaviour.96 services are quite resource intensive. Although Ontario has focused on reducing the rate of hospitalization for major depression,65, 92, 93 it still accounted for 18 percent ($80 million) of the province’s total direct health care costs for major depression in 2000.94 52 Research has found gender differences in hospital care for other health conditions, including heart attacks.97 We know women have a higher rate of hospitalization for depression.98 However, sex differences in the management and outcomes of acute and specialty Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C inpatient care for depression have not been previously reported for Ontario. This information is important for assessing whether there are gender inequities in the depression care delivered here. In this section we assess sex differences in patterns of acute and specialty inpatient care for depression. The evidence-based indicators for measuring process and outcomes in acute and speciality inpatient services were measured in patients admitted to hospital for depression and include: • Physician visits for depression within 30 days of discharge; • Average number of days post-discharge to first physician visit for depression; • Emergency department visits (with no subsequent hospital admission) within 30 days of discharge; • 30-day readmission rate for depression. These indicators are based on data from all Ontario hospitals submitting discharge records to the Canadian Institute for Health Information Discharge Abstracts Database (CIHI-DAD) which, at the time of writing, did not include four psychiatric or former psychiatric hospitals. However, because the vast majority of hospitalizations for depression are in general hospitals (all covered in the CIHI-DAD) and people admitted to the four speciality hospitals tend to stay longer and are less likely to be discharged within a year, the proportion of discharges for depression that could be missed should be quite small. The accuracy of the CIHI-DAD information on hospital stays for depression is considered quite high because of the precise diagnostic codes used. The first two indicators in this section measure physician visits for depression following hospitalization for depression. As noted in Section 5B, the definition of a physician visit for depression in this chapter is imprecise and may either under- or over-estimate the number of physician visits for depression care due to limitations of Ontario Health Insurance Plan (OHIP) codes for these visits (see Appendix 5.3 for more detail). Improving Health and Promoting Health Equity in Ontario © www.istockphoto.com 53 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBITS AND FINDINGS Physician visits for depression within 30 days of hospital discharge Indicator: This indicator measures the percentage of patients aged 15 and older hospitalized for depression who had a physician visit for depression within 30 days of discharge. Background: Post-discharge follow up care, including ongoing medical attention, is critical for people experiencing severe depression. Recent work in Ontario found that 80 to 90 percent of clients in community mental health programs or provincial hospitals are on psychotropic medication and that compliance and symptom and medication management are important concerns for these individuals.99 Findings: In Ontario, 63 percent of patients (65 percent of women and 60 percent of men) who were hospitalized for depression had a follow up physician visit for depression within 30 days of discharge. EXHIBIT 5C.1 | A ge-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and neighbourhood income quintile, in Ontario, 2005/06^ FINDINGS •Regardless of income, men were less likely than women to receive physician follow up after a hospital stay for depression. •Income was a significant factor in who received physician care following hospitalization for depression. Women and men living in lower-income neighbourhoods had lower rates of physician follow up than those from higher-income neighbourhoods. •Sex differences in physician follow up care persisted across age groups (data not shown). Percentage (%) •One in three Ontario women and men did not have a physician visit within 30 days of being discharged after a hospital stay for depression. 100 80 60 62 56 64 59 65 61 68 63 70 64 40 20 0 Q1 (lowest) Q2 Q3 Q4 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study 54 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C EXHIBIT 5C.2 | A ge-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and rural/urban residency, in Ontario, 2005/06^ FINDINGS •Urban residents who were hospitalized for depression were significantly more likely than rural residents to have a physician visit for depression within 30 days of hospital discharge (64 percent versus 59 percent) (data not shown). Percentage (%) •A larger percentage of women than men had a physician visit for depression within 30 days of discharge, irrespective of rural/ urban residency. 100 80 60 62 66 55 61 40 20 0 Rural Urban Rural/urban residency Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for definitions of rural/urban residency POWER Study Improving Health and Promoting Health Equity in Ontario 55 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 14 51% Overall Ontario In Ontario, 63% of all inpatient stays for depression were followed by one or more physician visits for depression within 30 days after discharge. Northern Ontario Northern Ontario 63% 0 H U D S O N H U D S O B N Y A B Y FINDINGS 13 •The unadjusted rates of physician visits for depression within 30 days of discharge varied significantly by LHIN. The rates were lowest in the South East LHIN (50 percent) and highest in the Central LHIN (72 percent). Overall Ontario Ontario InOverall Ontario, 63% of all inpatient stays for depression were followed by one or more physician visits for In Ontario, 63% of all inpatient stays for depression depression within 30 days after discharge. were followed by one or more physician visits for depression within 30 days after discharge. 59% 13 14 59% 51% 14 51% L A K E N I P I G O N 13 L A K E N I P I G O N Thunder Bay 63% Thunder Bay K E L A 63% 0 250 0 POWER Study 59% S U P E R I O R S U P E R I O K E L A Sudbury R Sudbury 500 Km 250 500 Km H U N R O 59% 9 10 6 68% 13 59% Hamilton 4 11 61% 64% 11 London 64% 1 Ottawa 9 57% 12 65% 9 57% Windsor 65% ^ People wh Ottawa 64% 12 10 50% 10L A K E E R I E 50% Kingston Barrie H E RNO R UO UH 2 2 59% N 1 56 61% Hamilton N T A R I O K E O L A N T A R I O O E K L A Southern Ontario Southern Ontario 50 0 0 50 100 Km 100 Km less than 60 60 to 65 less than 60 greater than 65 60 to 65 greater than 65 ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 64% Windsor 69% 6 4 1 7 Toronto Hamilton 68% 61% London 64% Windsor 6 4 London 69% Mississauga 68% Kitchener Markham 7 Toronto Mississauga Kitchener Markham 8 72% Orangeville Kingston Peterborough 72% 65% Orangeville 3 65% 59% 8 5 65% K Peterborough Barrie 65% 3 E A K L A 5 L E A K E A K L E R I E E R I E 9 65% Central East Barrie Peterborough South East 5 11 8 65% Champlain 72% Markham 12 North Simcoe Orangeville Muskoka 13 North East K E O 7 Toronto L A Kitchener 14 Mississauga North West 69% E 13 59% 12 57% Local Health Integration Networks (LHINs) 1 Erie St. Clair 4 Hamilton Niagara Haldimand Brant 2 South West L A 5 Central West 3 Waterloo K Wellington 3 6 Mississauga Halton 65% 7 Toronto Central 2 8 Central L 250 A EXHIBIT 5C.3 | Percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by Local Health Integration Network (LHIN), in Ontario, 2005/06^ Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP) Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C EXHIBIT 5C.4 | A ge-standardized percentage of patients aged 15 and older admitted to hospital for depression who had a physician visit for depression within 30 days of discharge, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06^ Percentage (%) 100 80 65 64 60 62 68 56 62 62 59 66 72 62 71 62 67 74 70 67 68 63 53 57 62 60 51 45 56 50 52 40 20 0 1 2 3 Women 4 5 6 7 8 9 10 11 12 13 14 Men Local Health Integration Network (LHIN) 1. Erie St. Clair 6. Mississauga Halton 11. Champlain 2. South West 7. Toronto Central 12. North Simcoe Muskoka 3. Waterloo Wellington 8. Central 13. North East 4. Hamilton Niagara Haldimand Brant 9. Central East 14. North West 5. Central West 10. South East Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP) ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 FINDINGS •The age-standardized rates of physician visits for depression within 30 days of discharge from hospital were higher among women than men in most LHINs. •The age-standardized rates of physician visits within 30 days showed significant regional variation for both sexes. Among women, rates ranged from 50 percent in the North West LHIN to 74 percent in the Central LHIN; among men, rates ranged from 45 percent in the South East LHIN to 70 percent in the Central LHIN. POWER Study Improving Health and Promoting Health Equity in Ontario 57 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Time from hospital discharge to first physician visit for depression Indicators: Two indicators measure the time from discharge to the first physician visit for depression among patients hospitalized for depression. The first is the percentage of discharged patients aged 15 and older who had a physician visit for depression within 30 days (see also the previous indicator), 30 days to 12 weeks, 12 weeks to six months and six to 12 months, as well as those who did not see a physician for depression in the year after discharge. The second is the mean number of days to the first physician visit for those who were seen by a physician within one year of discharge from hospital. Background: The first visit is used as a proxy for the promptness of adequate follow up. Prompt follow up after discharge may help prevent unnecessary readmission to hospital. Findings: In Ontario, 10 percent of women and 14 percent of men aged 15 and older were not seen by a physician within one year of hospital discharge. People who had been hospitalized for depression and who were seen within 30 days of discharge, had an average of 9.6 days for women and 9.7 days for men to their first physician visit for depression. Over the course of one year, the average time to a physician visit was 37 days for women and 41 days for men. EXHIBIT 5C.5 | P ercentage of patients aged 15 and older admitted to hospital for depression who had a post-discharge physician visit for depression, by sex and time from discharge, 2005/06^ FINDINGS •The gender gap did not narrow over time: 10 percent of women and 14 percent of men had no physician visit for depression in the 12 months after they were discharged from hospital. •The time between discharge and a first physician visit for depression, among people seen within the first 30 days, did not differ by sex (9.6 days for women and 9.7 days for men), but it did differ for people who were seen over the course of a year (data not shown). Percentage (%) •Less than two-thirds of women (65 percent) and men (60 percent) had a physician visit for depression within 30 days of hospital discharge. Women were somewhat more likely than men to have had a visit within this period. 100 80 60 65 60 40 20 0 14 14 <30 days >30 days to 12 weeks 7 7 5 5 >12 weeks to 6 months >6 months to 12 months 10 14 No visit within 12 months Time from discharge Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP) ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 POWER Study 58 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C FINDINGS •Following a hospitalization for depression, people living in lower-income neighbourhoods had a longer time to a physician visit for depression than those from higher-income neighbourhoods (43 days versus 34 days, respectively) (data not shown). Number of days (mean) EXHIBIT 5C.6 | M ean number of days to a first physician visit¥ for depression in patients aged 15 and older admitted to hospital for depression, by sex and neighbourhood income quintile, in Ontario, 2005/06^ 50 43 38 37 37 38 33 38 32 30 20 10 0 •The mean number of days to the first physician visit for depression varied significantly by income for women and men. 43 43 40 Q1 (lowest) Q2 Q3 Q4 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census ¥For patients who were seen by a physician within 12 months of discharge ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 59 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 FINDINGS •Across all age groups, the mean number of days between discharge to the first physician visit for depression was longer for men than women. •On average, those aged 15-24 had a significantly longer time to a physician visit for depression than other age groups. The mean number of days to the first visit were similar in the other age groups. Number of days (mean) EXHIBIT 5C.7 | M ean number of days to a first physician visit¥ for depression in patients aged 15 and older admitted to hospital for depression, by sex and age group, in Ontario, 2005/06^ 50 40 46 41 40 36 37 39 37 39 30 20 10 0 15-24 25-44 45-64 65+ Age group (years) Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP) ¥For patients who were seen by a physician within 12 months of discharge ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 POWER Study 60 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C 30-day post-discharge rate of emergency department (ED) visits (with no subsequent hospital admission) Indicator: This indicator measures the percentage of Ontarians aged 15 and older who were hospitalized for depression who had an emergency department (ED) visit (but were not readmitted) within 30 days of being discharged. Background: A high percentage of patients visiting an ED shortly after their discharge from an inpatient stay for depression may signal less-than-optimal continuity of care.58 A high rate may reflect poor discharge planning, a lack of appropriate community supports or poor integration with community services. Findings: In Ontario, 17 percent of patients aged 15 and older (17 percent of women and 18 percent of men) who had been in hospital for depression were seen in an ED within 30 days of discharge, but were not readmitted at that time. EXHIBIT 5C.8 | A ge-standardized percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and neighbourhood income quintile, in Ontario, 2005/06^ FINDINGS Percentage (%) •There was significant income variation in the percentage of men who had an ED visit within 30 days of discharge from hospital; 22 percent of men from lowerincome neighbourhoods were seen in an ED compared to 13 percent of men from higher-income neighbourhoods. The income difference among women was smaller. 50 40 30 20 19 22 16 18 15 18 15 16 17 13 10 0 Q1 (lowest) Q2 Q3 Q4 Q5 (highest) Neighbourhood income quintile Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); National Ambulatory Care Reporting System (NACRS); Statistics Canada 2001 Census ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 Note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 61 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5C.9 | P ercentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and age group, in Ontario, 2005/06^ FINDINGS •In the youngest age group, 19 percent of women versus 14 percent of men were seen in an ED in the 30 days following a hospital stay for depression. This pattern was reversed among those aged 45-64, with 15 percent of women and 19 percent of men being seen in an ED within 30 days. •ED visits within 30 days of hospital discharge were more common among rural residents than urban residents (21 percent versus 16 percent, respectively) (data not shown). Percentage (%) •Ontarians aged 65 and older were less likely to be seen in an ED in the 30 days following a hospital stay for depression. The rate in this age group was 13 percent, compared to a combined rate of 18 percent for those under age 65 (data not shown). 50 40 30 20 19 20 19 14 15 19 13 14 10 0 15-24 25-44 45-64 65+ Age group (years) Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); National Ambulatory Care Reporting System (NACRS) ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 POWER Study 62 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C 14 19% Overall Ontario In Ontario, 17% of patients with depression had ED visits without a resulting hospitalization within 30 days of discharge from hospital. Northern Ontario Northern Ontario 17% 0 H U D S O N H U D S O 250 B N A EXHIBIT 5C.10 | Percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by Local Health Integration Network (LHIN), in Ontario, 2005/06^ Y A B Y FINDINGS 13 21% •There was significant regional variation in the percentage of people who visited an ED within 30 days of discharge after a hospital stay for depression. The unadjusted rates ranged from 11 percent in the Central West LHIN to 21 Overall Ontario percent in the South West, South East and North East InOverall Ontario, Ontario 17% of patients with depression LHINs. had ED visits without a resulting hospitalization In Ontario, 17% of patients with depression within 30 days of discharge from hospital. had ED visits without a resulting hospitalization within 30 days of discharge from hospital. 13 14 21% 19% 14 19% L A K E N I P I G O N 13 L A K E N I P I G O N Thunder Bay 17% Thunder Bay S U P E R I O K E L A 17% R S U P E R I O K E L A 0 250 0 21% Sudbury R Sudbury 500 Km 250 12 9 15% 18% 500 Km POWER Study Local Health Integration Networks (LHINs) 1 Erie St. Clair 4 Hamilton Niagara Haldimand Brant 2 South West L A 5 Central West 3 Waterloo K Wellington 3 6 Mississauga Halton 14% 7 Toronto Central 2 8 Central 21% E Central East Barrie Peterborough South East 8 11 Champlain 11% 15% 12 North Simcoe Markham Orangeville Muskoka 13 North East 7 Toronto K E O L A Kitchener 14Mississauga 19% North West 6 H U N R O 13 21% 9 510 14% 13 21% Hamilton 4 11 16% 18% 11 London Ottawa 18% 1 9 15% 12 18% 9 15% Windsor 18% ^ People who Ottawa 13% 12 10 21% A 10 L K E E R I E 21% Kingston Barrie L H E N RNO R UO UH 2 2 21% 1 6 6 Hamilton 14% 16% 4 Hamilton 16% London 13% 1 Windsor 7 Toronto 19% N T A R I O K E O L A N T A R I O O E K L A Southern Ontario Southern Ontario 0 0 50 50 100 Km 100 Km less than 15 15 to 18 less than 15 19 and higher 15 to 18 19 and higher ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 13% Windsor 19% Mississauga 14% 4 Markham 7 Toronto Mississauga Kitchener London 15% Orangeville Kitchener Markham 8 11% Orangeville 3 Kingston Peterborough 15% 14% 21% 8 5 14% K Peterborough Barrie 11% 3 E A K L A 5 L E A K E A K L E R I E E R I E Improving Health and Promoting Health Equity in Ontario Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); National Ambulatory Care Reporting System (NACRS) 63 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 EXHIBIT 5C.11 | A ge-standardized percentage of patients aged 15 and older hospitalized for depression who were seen in an emergency department (ED) within 30 days of discharge without a subsequent hospitalization, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06^ Percentage (%) 50 40 30 25 21 21 20 12 14 14 14 15 16 3 4 10 10 0 1 2 Women 14 5 20 16 17 11 6 7 15 14 8 17 20 9 17 10 19 17 11 25 21 22 15 15 12 13 13 14 Men Local Health Integration Network (LHIN) 1. Erie St. Clair 6. Mississauga Halton 11. Champlain 2. South West 7. Toronto Central 12. North Simcoe Muskoka 3. Waterloo Wellington 8. Central 13. North East 9. Central East 14. North West 4. Hamilton Niagara Haldimand Brant 5. Central West 10. South East Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); National Ambulatory Care Reporting System (NACRS) ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 FINDINGS •There was significant regional variation in the age-standardized rates of ED visits within 30 days of discharge after a hospital stay for depression. Among women, the rates ranged from 10 percent in the Central West LHIN to 21 percent in the South West and North East LHINs. Among men, the rates ranged from 11 percent in the Mississauga Halton LHIN to 25 percent in the South East and North West LHINs. POWER Study 64 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C 30-day readmission rate for depression Indicator: This indicator measures the percentage of patients aged 15 and older who were readmitted to hospital for depression in the 30 days post-discharge after a hospital stay for depression. Background: The role of inpatient care in mental health is to stabilize individuals experiencing acute episodes of illness so they can be discharged to community-based services and supports. Readmission to hospital shortly after a previous inpatient stay suggests problems in the continuity of care. It may indicate inadequate preparation for discharge, poor community-based follow up or a lack of adequate community services. For this indicator, readmissions can be to the same or a different hospital, but transfers between hospitals are not considered readmissions. Since this may be an access issue, rates may vary by geographic location, sex, or other population subgroups. Finding: In Ontario, 7.6 percent of both women and men aged 15 and older who had been hospitalized for depression were readmitted to hospital for depression within 30 days of discharge. EXHIBIT 5C.12 | A ge-standardized 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by sex and neighbourhood income quintile, in Ontario, 2005/06^ FINDINGS •Readmission rates for depression did not vary by age group or rural/urban residency (data not shown). Percentage (%) •Readmission rates did not vary by income for women or men. 25 20 15 10 8.0 7.2 7.4 9.0 6.7 6.5 7.5 7.1 8.2 8.0 Q3 Q4 Q5 (highest) 5 0 Q1 (lowest) Q2 Neighbourhood income quintile Women Men Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Statistics Canada 2001 Census ^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006 note: See Appendix 5.3 for details about neighbourhood income quintile calculation POWER Study Improving Health and Promoting Health Equity in Ontario 65 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 14 9.2% Overall Ontario EXHIBIT 5C.13 | 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by Local Health Integration Network (LHIN), in Ontario, 2005/06^ In Ontario, 7.6% of all inpatient stays for depression were followed by readmission within 30 days after discharge. Northern Ontario Northern Ontario 7.6% 0 H U D S O N H U D S O B A N 250 Y A B Y FINDINGS 13 •Unadjusted readmission rates for depression showed significant regional variation. 11.9% 11.9% 14 •Readmission rates ranged from 2.9 percent in the Erie St. Clair LHIN to 11.9 percent in the North East LHIN. Overall Ontario InOverall Ontario, Ontario 7.6% of all inpatient stays for depression were followed by readmission within 30for days after In Ontario, 7.6% of all inpatient stays depression discharge. were followed by readmission within 30 days after 13 14 9.2% 9.2% L A K E N I P I G O N L A K E N I P I G O N 13 11.9% Thunder Bay 7.6% discharge. Thunder Bay S U P E R I O K E L A 7.6% R S U P E R I O K E L A 0 250 0 POWER Study Sudbury R Sudbury 500 Km 250 500 Km Local Health Integration Networks (LHINs) 1 Erie St. Clair 4 Hamilton Niagara Haldimand Brant 2 South West L A 5 Central West 3 Waterloo K Wellington 3 6 Mississauga Halton 8.4% 7 Toronto Central 2 8 Central H U N R O 7.9% 9 10 8.9% 13 11.9% Hamilton 4 11 7.2% 7.4% 11 London Ottawa 7.4% 1 9 3.6% 12 7.0% 9 3.6% Windsor 7.0% ^ People wh Ottawa 2.9% 12 10 5.1% 10L A K E E R I E 5.1% Kingston Barrie L H E RNO RUO UH 2 7.9% 2 7.9% Kitchener 4 Hamilton N T A R I O K E O L A N T A R I O O E K L A Southern Ontario Southern Ontario 0 0 50 50 100 Km 100 Km less than 6.0 6.0 to 8.0 less than 6.0 greater than 8.0 6.0 to 8.0 greater than 8.0 ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 2.9% 66 6 7.2% London Markham 7 Toronto Hamilton 8.9% 7.2% 1 Markham 10.1% 6 7 Toronto Mississauga 8.9% 10.1% Kitchener N 1 8 6.3% Mississauga Kingston Peterborough 6.3% Orangeville 4 2.9% Windsor 5.2% Orangeville 3 8.4% London Windsor 8 5 8.4% K Peterborough Barrie 5.2% 3 E A K L A 5 L E A K E A K L E R I E E R I E 9 7.0% Central East Barrie Peterborough South East 5 8 11 Champlain 5.2% 6.3% Markham 12 North Simcoe Orangeville Muskoka 13 North East K E O 7 Toronto L A Kitchener 14Mississauga 10.1% North West 6 E 13 11.9% 12 3.6% Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Section 5C EXHIBIT 5C.14 | A ge-standardized 30-day readmission rate (percentage) for depression among patients aged 15 and older admitted to hospital for depression, by sex and Local Health Integration Network (LHIN), in Ontario, 2005/06^ Percentage (%) 25 20 15 9.4 10 5 0 6.8 9.0 7.5 7.2 7.2 9.4 5.5 3.2 2.6 1 2 Women 3 4 7.9 9.7 5.8 4.5 5 6 12.1 11.4 10.7 7 7.3 6.9 7.2 8 9 8.3 8.2 4.6 5.4 10 5.9 11 4.5 10.1 2.3 12 13 14 Men Local Health Integration Network (LHIN) 1. Erie St. Clair 6. Mississauga Halton 11. Champlain 2. South West 7. Toronto Central 12. North Simcoe Muskoka 3. Waterloo Wellington 8. Central 13. North East 4. Hamilton Niagara Haldimand Brant 9. Central East 14. North West 5. Central West 10. South East Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) ^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006 FINDINGS •Age-standardized readmission rates for depression varied significantly across LHINs for both sexes. The rates for women ranged from 3.2 percent (Erie St. Clair LHIN) to 12.1 percent (North East LHIN). For men, the rates ranged from 2.3 percent (North Simcoe Muskoka LHIN) to 11.4 percent (North East LHIN). POWER Study Improving Health and Promoting Health Equity in Ontario 67 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Section 5C Summary of FIndings The indicators of acute and specialty inpatient services all post-discharge physician visit for depression within 30 focus on the care a person who has been hospitalized for days than those living in lower-income neighbourhoods depression receives post-discharge. While the quality and or rural areas. The largest differences, however, were outcomes of the care delivered in hospital are important, across LHINs, where the rates ranged from 50 percent the primary purpose is to stabilize depressed patients to 72 percent. to the point that they can benefit from less structured Women and men were equally likely to receive care in and less intensive community or outpatient services. an emergency department after being discharged (17 The assumption is that a poor transition from hospital percent and 18 percent, respectively). Men living in the to community care will undo the gains the individual lowest-income neighbourhoods were more likely to visit made in hospital and also will undermine the value of keeping people in the community and providing the least restrictive care possible.65 Higher rates of physician visits for depression after a hospital stay and lower rates of emergency department visits or hospital readmissions are therefore desirable. an emergency department than men from the highestincome neighbourhoods and men from rural areas were more likely to return to an emergency department than those from urban areas. Sex disparities occurred within age groups; women aged 15-24 had a higher rate of emergency department visits than men that age, but Overall, one in three Ontarians did not see a physician for depression after a hospital stay for depression, men aged 45-64 had higher rates of use than women. As was the case for physician care for depression, the indicating suboptimal care coordination in transition largest differences were across LHINs. The highest from the hospital to the community. Women were rate (21 percent) was almost double the lowest rate consistently more likely than men to have seen a physician for depression after discharge from hospital. (11 percent). This pattern held true across neighbourhood income Men and women were equally likely to be readmitted levels, rural/urban residency and almost all LHINs. The to hospital for depression within 30 days post-discharge difference was apparent in the first 30 days after hos- (7.6 percent for each). There were few differences in pitalization (65 percent of women versus 60 percent of readmission rates across age groups, neighbourhood men) and had not gone away even after a year post-dis- income levels and rural/urban residency. There were charge, by which time 90 percent of women had seen differences across LHINs, however, where rates ranged a physician for depression versus 86 percent of men. from 2.9 percent to 11.9 percent. It is often argued that There was no difference by sex in how long women high readmission rates may result from hospital stays and men took to get a follow up visit within the first 30 that are too short but the literature shows the relation- days of discharge. Beyond 30 days, men had somewhat ship is not that straightforward and high readmission longer times to a physician visit. rates occur in situations with both shorter and longer lengths of stay.100 People living in higher-income neighbourhoods and those living in urban areas were more likely to have a 68 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Depression Section 5C © www.istockphoto.com Improving Health and Promoting Health Equity in Ontario 69 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Chapter Summary of Findings In this chapter, we presented background information There were also gender and sociodemographic on the need, use and supply of depression care in differences in which service sectors were used. Women Ontario, as well as indicators of inpatient and outpatient and men living in lower-income neighbourhoods were depression care. Figure 5 provides a summary of where almost twice as likely to be hospitalized for depression sex, income, age and regional differences were found. but incurred slightly lower average costs for OHIP core mental health services compared to Ontarians living in Overall, we found many instances where depression the highest-income neighbourhoods. Rural residents care was suboptimal for everyone. Less than half were more likely to be hospitalized for depression while of women and men with probable depression (as urban dwellers accounted for proportionately greater reported in a national survey) had a physician visit for this condition within one year. Many older adults OHIP costs for mental health care. who started on antidepressant therapy did not receive A comparison of need, use and supply across Local the recommended number of follow up visits for Health Integration Networks (LHINs) suggested that the medication management. One in three women and geographic patterns of use reflected the geographic men hospitalized for depression did not have a follow distribution of supply more than need. up physician visit for depression within 30 days of hospital discharge and nearly one in five patients had an emergency department visit in this time frame, We reported results for several indicators of depression care. For some indicators, we found no significant sex differences. Women and men with probable indicating suboptimal care coordination during depression had similar rates of having a physician visit care transitions. for depression within a one-year period. Men and We found differences in the prevalence of depression— women aged 66 and older who started on a new one of the important markers of need for depression course of antidepressants were equally likely to have care—across sex, age, income and geography. We had the recommended number of physician follow up also found differences in the use of services for both visits. And women and men who were hospitalized for depression and mental health in general. In some cases, depression were equally likely to be readmitted or to the prevalence patterns were similar to the service use have visited an emergency department in the month patterns. For example, women had higher rates of after they were discharged. both depression and use of Ontario Health Insurance Plan (OHIP) core mental health services. In other cases, however, the patterns differed. For example, lowerdepression but had the same rate of use of OHIP core 70 who were hospitalized for depression, women were more likely than men to have had a physician visit for income women were more likely to report probable mental health services as higher-income women. There were some gender differences. Among people depression within 30 days of discharge. For those who were seen by a physician within 30 days of discharge, there was no difference in the mean time women and Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Summary of Findings men took to have their first physician follow up visit. do so more quickly) than those from lower-income Beyond 30 days, men took somewhat longer to see neighbourhoods. And, men living in the lowest-income a physician. neighbourhoods were more likely than men from the A few indicators of depression care were associated with age. Ontarians with probable depression aged 45-64 were the most likely to have had a physician visit highest-income neighbourhoods to visit the emergency department in the one month period post-discharge after a hospital stay for depression. for depression, although they were not the group with Some rural/urban differences were seen. People living in the highest prevalence. Among older Ontarians starting urban areas were more likely to have a post-discharge antidepressants, age was associated with a decreasing physician visit for depression than people living in rural likelihood of adequate follow up (i.e., three or more areas. Also, men from rural areas were more likely to within the 12 weeks after starting medication) for visit an emergency department after discharge than depression but an increasing likelihood of having had those from urban areas. three or more physician visits for any reason. Variations across Local Health Integration Networks Disparities by income were found in several indicators. (LHINs) were seen for a number of indicators, and Among women with probable depression, those who these represented the largest disparities reported in this had lower household incomes were more likely to chapter. Differences between the highest and lowest see a physician for depression than those with higher LHINs ranged from roughly one and a half times as large household incomes. However, among women aged 66 (physician visits for depression within 30 days of hospital and older who had started antidepressants, those from discharge) to twice as large (percentage of adults aged lower-income neighbourhoods were less likely to have 66 and older, starting a new course of antidepressants had the recommended number of follow up physician who had three or more physician visits for depression visits for depression than women from higher-income within 12 weeks of starting medication; 30-day post- neighbourhoods. Among Ontarians who had been discharge rate of emergency department visits) to as hospitalized for depression, people who lived in higher- much as four times as large (30-day readmission rate income neighbourhoods were more likely to have a for depression). post-discharge physician visit for depression (and to Improving Health and Promoting Health Equity in Ontario 71 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Figure 5 | S ummary of differences by sex, age, income and LHIN for background measures and indicators of depression care Indicator Stratification Factor Overall Result Sex Age Income LHIN Background Information: Need, Use and Supply of Medical Services (8 measures) 7.4% Y Y Y Y Fair or poor self-rated health 29% N Y* N* N* No other comorbid chronic medical conditions 33% Y Y* N N* Number of days 'out of bed' 13 days N Y N N Number of days without cutting down activities 12 days N N N N Rate of hospitalization for depression 108 per 100,000 Y Y Y Y OHIP core mental health care users^ 15% Y Y N Y OHIP core mental health services costs per capita^ $33 per capita Y Y Y Y Electroconvulsive therapy (ECT) use 15 per 100,000 Y Y N Y Number of general practitioners / family physicians and psychiatrists 19-105 per 100,000 • • • Y Number of acute hospital psychiatric beds 51 per 100,000 • • • Y Prevalence of probable depression Health and functional status Primary and Specialty Outpatient Care ( 3 indicators) Physician visit for depression 40% N Y N* N* Three physician visits within 12 weeks of starting medication 9.6% N Y Y Y Physician visit for depression within one year after giving birth 20% • Y N Y Physician visit within 30 days of hospital discharge 63% Y N Y Y Time from hospital discharge to first physician visit for patients seen within 30 days of discharge 9.6 days N N Y Y 30-day post-discharge rate of emergency department visits 17% N Y Y Y 30-day readmission rate for depression 7.6% N N N Y Acute and Specialty Inpatient Care ( 4 indicators) • Not applicable * Based on some values that should be interpreted with caution ^ Confidence intervals for values are extremely small POWER Study 72 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion Discussion Depression, the leading cause of disease-related disability among women, puts a tremendous burden on the people suffering from it, their families and society as whole. Almost five percent of Ontario’s population experiences and a half times more likely than Ontario men to receive an episode of depression in any 12-month period. electroconvulsive therapy (ECT) or be hospitalized for Women are twice as likely as men to experience depression. depression. 8 Among those Ontarians with probable depression in the Previous research has shown that women’s experiences community, we found no important differences between with depression are different from men’s. They tend women and men in their overall access to physician care to be younger when they have their first episode of for depression. Interestingly, the self-perceived health and depression, have poorer social adjustment and lower self-reported disability of women and men with probable 19 quality of life and report more severe episodes and more chronic depression than men. Men are more likely to develop alcohol and substance abuse problems 23 and have higher suicide rates. 22 Clearly, depression depression in Ontario were similar. However, among individuals who were hospitalized, women were more likely than men to see their physician after they had been discharged. causes great suffering for both sexes and our goal, as we developed indicators for this chapter, was to help Age also makes a difference. ensure high quality mental health care for all Ontarians Ontarians aged 15-24—the age group with the highest with depression. rate of depression—were least likely to see a doctor We found disparities in depression care in Ontario related to sex, income, age and geography. The findings suggest a need for improvement in several areas, including access to and the distribution and organization of mental health for the problem. Younger Ontario women were also more likely than older women to visit an emergency department within 30 days of discharge after a hospital stay for depression. care. In particular, our research suggests there may be Among Ontario seniors who had started a new breakdowns in care continuity and a need for more prescription for antidepressants, the oldest women and collaborative approaches to managing depression—an men—those aged 81 and older—were the least likely to area where Local Health Integration Networks (LHINs) have had the recommended number of physician follow have an important role to play. up visits (i.e., three visits for depression within the first 12 weeks) for monitoring their medication use. Gender makes a difference. Because women have a higher prevalence of depression Socioeconomic status makes an even than men, you would expect that they use depression bigger difference. care in greater numbers. For some kinds of care, this Socioeconomic status was associated with access to was indeed the case: Ontario women were more likely care for depression. Ontarians living in the highest- to visit a physician for depression and were roughly one income neighbourhoods were more likely to see a Improving Health and Promoting Health Equity in Ontario 73 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 physician after a hospital stay for depression, and to may reflect rural/urban differences (e.g., LHINs with the do so more quickly, than those living in lower-income largest urban concentrations tend to have better rates neighbourhoods. People living in the lowest-income of physician follow up or visits for monitoring older neighbourhoods were the most likely to visit an patients who were starting antidepressant medication). emergency department after a hospital stay, an Some of the variation reflects known regional differ- indicator of suboptimal care coordination during ences—for example, care in northern Ontario relies transition from hospital to home. Women with more on inpatient services58 than in other parts of the probable depression who were living in the lowest- province. income neighbourhoods were more likely than men and higher-income women to have a physician visit These differences in use do not reflect for depression. This could be consistent with a study differences in need. that found fewer socioeconomic differences in use Patterns of use of depression services often did not of depression care services in Ontario compared to reflect differences in assessed need. We found patterns several other jurisdictions. However, more work needs of depression care across neighbourhood income, rural/ to be done to determine whether this reflects actual urban residency and LHINs that did not reflect the use patterns, differences in coding or differential use prevalence of probable depression (Section 5A). In the of mental health services not covered by OHIP. case of neighbourhood income, prevalence and supply For older Ontarians (aged 66 and older) starting a new course of antidepressant medication, those from the highest-income areas were more likely than lowerincome seniors to receive the recommended number of follow up visits. of care were opposite; depression rates were highest among women and men living in the lowest-income neighbourhoods, but OHIP spending on care was highest for those residing in the highest-income neighbourhoods. In comparing rural and urban locations, we found significant differences in care for depression, although there were no significant differences in Geography also makes a big difference. prevalence. Across LHINs, the magnitude and patterns Rural Ontarians were less likely than urban residents to have a physician visit for depression after being hospitalized and they had a longer time between hospital discharge and their first visit. They were also more likely than urban residents to visit an emergency department in the month following their hospital stay. of differences in care were larger than differences in prevalence. Because there are no consistently accepted benchmarks, the implications of the mismatch between indicators of depression care and measures of prevalence cannot be fully assessed. However, as noted in Section 5A, it is important to consider why the The largest and most consistent differences seen were availability of services seems to have more influence on across LHINs, where there were significant differences the care people receive than level of need. More work in almost every indicator. One exception was ‘percent is needed to better understand the reasons for these of individuals with probable depression who had a differences and barriers to care encountered by specific physician visit for depression’ where the numbers were population subgroups. too small to allow reporting. Some of these differences 74 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion There are important gaps in depression care according to guidelines is clinically important. It is also in Ontario for everyone regardless of sex, important to assess the management of antidepressant income, age or where one lives. therapy in those under age 65. However, this is not There were gaps everywhere in Ontario, for all possible using data currently available in the province. population groups, between the desired or Finally, we know the most effective treatment for recommended depression care and the care that was depression often combines medication and psycho- delivered. Less than 50 percent of people who reported therapy.107 While it is possible that psychotherapy is probable depression saw a doctor for depression in taking place in more broadly defined follow up visits, it the year following their interview. This indicator does seems unlikely given that effective treatment requires a not include visits to non-medical mental health profes- lengthier visit and there is a financial incentive to code sionals, but physicians are the most common provider these visits using a small set of specified codes. All these of depression care.7, 67, 101, 102 Because depression is a findings raise questions about the quality of care being recurrent disease and often is associated with a 'silent' delivered to older Ontarians who take antidepressants. or partly visible disability,103 this finding suggests there People who have been hospitalized for depression often are missed opportunities to intervene early in what have severe and quite debilitating forms of the illness, becomes a chronic illness for many Ontarians. but only 63 percent of them had a physician visit for Less than ten percent of people aged 66 and older depression in the 30 days after they were discharged. who started a new course of antidepressant medication While depression can be stabilized by inpatient care, received the recommended number of physician follow continued follow up in the community, including up visits for depression. It is possible this number monitoring and treatment by a physician is necessary underestimates the actual number of people who are to ensure gains made in hospital are not lost and, for adequately monitored, because the monitoring may those taking medication, that problems with side effects happen during physician visits for other conditions. If or dosages are addressed. we assume that is what is happening, then the rate Up to one-quarter of all hospital stays for depression of adequate follow up increases to a more reassuring were followed by a readmission or a visit to the range of 80 to 90 percent. However, since there is no emergency department within 30 days of discharge. definitive way of determining whether antidepres- Turning to these resource-intensive services within a sants are being monitored in more broadly defined fairly short time is a less desirable outcome for patients physician visits and we know from the literature that than being maintained with outpatient care and depression is frequently under-recognized and under- community support.65 treated in primary care settings and among individuals with comorbid chronic medical conditions, this is still an Depression as a chronic illness: the need for area for concern. This indicator is used internationally collaborative care. to assess the quality of depression care and we need Findings of suboptimal access, quality and outcomes to improve the capacity to better assess this dimension of depression care are not new. Reports over two of depression care through improvements in data decades and from around the world9, 76, 79, 108, 109 have comprehensiveness. Individuals with depression are a consistently documented large gaps where individuals 104, 105 potentially fragile population pressants have severe side effects, and some antide- 106 so monitoring Improving Health and Promoting Health Equity in Ontario with depression do not seek care or are not recognized as needing care. Because there is solid evidence that 75 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 effective treatments for depression are available, access to psychiatric professionals for advise, these gaps have led to campaigns to raise public and consultation and referral.119 Patients who do not individual awareness of depression and to educate respond to initial therapy may have their treatment physicians, families and employers about its nature and modified by the primary care physician in consultation severity. But the impact of these campaigns has been with a psychiatrist, be referred for management by 110-114 a psychiatrist or other mental health professionals or limited. referred for additional mental health services depending The current understanding of depression is that it is a chronic disease,42 like diabetes or coronary heart disease, and it may be that past approaches to managing it failed because they tried single solutions to a complex problem. Examples from other jurisdictions show that collaborative care is an effective approach to the diagnosis and management of depression.13, 14, 109, 115 Collaborative care is multifaceted, involving the client, providers and the broader mental health system all at once. Typically: • Clients are involved in developing their treatment plan (including setting goals for self-management) and then are provided with sustained follow up; upon response to therapy or severity of illness.119 Stepped care is typically a component of collaborative care models, but may be implemented separately. Additionally, mechanisms for providing self-management support to patients either through written materials120 or via the internet121 have been developed and have shown some benefit. The internet also holds promise as a tool for prevention, diagnosis and management of depression. A web-based, screening instrument for the diagnosis of depression in primary care shows promise.122 Both patient information on depression and online cognitive • Clients’ progress is systematically evaluated and those evaluations are used to modify the treatment plan; behavioural therapy have been shown to improve depression outcomes.121, 123 • Primary care providers work with a multidisciplinary team including mental health professionals to make and implement decisions about the client’s care and • Communication among the care team is systematically evaluated to identify breakdowns in information flow or interruptions in care.116, 117 The need for policy and programs to address the social determinants of inequitable care. The observed disparities in depression care across sex, age and geography suggest a need for provinceand LHIN-wide interventions for improvement (see Improving Depression Care: Different Approaches). Clients cared for in a collaborative model are more likely They also highlight the need to address social deter- to receive evidence-based care, to follow their care plan minants to reduce the risk of developing depression. and to report greater satisfaction with their care. Their There are perennial requests for increased resources symptoms and functioning improve more rapidly, the to deliver more services, which would be consistent benefits last longer and there are greater cost benefits with some of the background findings we reported in compared to other forms of depression care.13, 117, 118 Section 5A. However, those findings also suggest that Other approaches such as stepped care models, patient a simple increase in the amount of care available is self-management support and e-health interventions through use of the internet also hold promise. In stepped care models, primary care physicians diagnose and treat mild to moderate depression and have ready 76 not enough. The large variations found by neighbourhood income, rural/urban residency and across LHINs suggest how resources are distributed and organized are also important factors in access to care. Importantly, mechanisms need to be put in place to better measure Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion telephone can improve outcomes.130, 131 In addition, access, quality and outcomes of depression care. Collaborative care models can address both suboptimal quality and disparities in depression care in primary care—the main source of formal medical depression care for most Ontarians. Improved coordination across telemedicine has been used in rural settings with some success to improve access to mental health professionals and to adapt the collaborative care model to rural primary care practices.132 primary care, community agencies and inpatient care How to reach patients who need care but have not is particularly important to ensure that people with sought it is another issue, since many of the studies more severe and debilitating forms of depression get we looked at were done in clinics regularly delivering high quality care. Additional measures used in the care to members of underserved groups. There is 58 Hospital Report 2007 or under development, such some evidence that outreach may be effective,133 but as the number of days psychiatric patients spend it needs to be tailored and can be time consuming to in hospital after they have been judged ready to be establish.134 discharged58 and how long people wait in emergency to see a psychiatrist124 also suggest a need for more, and more effective, coordination of mental health care. Ontario has made some significant investments in community mental health agencies and programs such as assertive community treatment and intensive case management.90 Other initiatives include the Finally, policy and outreach efforts in mental health care must be coordinated with larger initiatives. In particular, policies to address the underlying issues of poverty and delivering care in diverse geographic location and policies and programs to better integrate depression care with other types of health care services, particularly chronic disease management, can have a tremendous development of coordinated access programs and care-planning tables in LHINs and hospitals across the province125, 126 as well as models for improving postdischarge transitions127 and mental health care in the emergency room.128 Most of these programs however, are limited in scope, organized within community-based services or linking community and hospital-based care. impact on care for depression. The need for improved measurement tools. With the data we have, we can only do a piecemeal evaluation of coordinated care (see ‘What we can’t measure’ below). Information on individual sectors of care—such as we present in this chapter—is valuable, Research on models of coordinated care shows but an integrated system of mental health care (the goal promising results for several groups—men, younger of several Ontario governments over the years)65, 92, 93 people, older adults and those with low-incomes—all requires data on transitions between services and their groups we found had less access to care. 35, 118, 129 While cumulative contribution to outcomes for depression. specific outcomes may differ (e.g., some groups take We have captured some of those transitions in our longer to show improvement than others), the positive data, particularly how people contact health services results appear to be consistent even when models after discharge from a hospital stay for depression. But are adapted to allow for the needs of the particular without integrated data on all sectors of care, we have populations and providers involved. 116 An important question for Ontario may be how to only a limited sense of how many people fall through the cracks, or of who they are. adapt collaborative care for rural areas, since most of Indicators used in other jurisdictions to assess the research has been conducted in large organizations. depression care, but not feasible with Ontario data, tell There is some promise that managing depression by us where efforts to gather better data on coordinated Improving Health and Promoting Health Equity in Ontario 77 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 care could begin. In addition, other jurisdictions have income, can accurately capture an area’s overall used client satisfaction, cost-effectiveness, timely characteristics, but they may not reflect the factors communication among care providers and outcomes that influence people individually. (such as symptom or functioning levels) to evaluate the success of coordinated care, which Ontario could also consider. Thirdly, the data in this chapter are not current—they date from 2001 and 2005/06. However, they provide a baseline for comparison as newer information becomes available. Limitations As noted throughout this chapter, these indicators What we can’t measure have a number of limitations that need to be As we developed the indicators for this chapter, we considered in their interpretation. The indicators indicate where disparities are likely and it is possible to track them across time to assess progress. They do not include enough detail to explain why disparities occur, so they cannot dictate solutions. found several aspects of depression care we could not measure, because of three main barriers. For some potential indicators, there were no Ontario-wide data. For example, none of the measures relating to care in community mental health settings could be calculated Secondly, there are limitations inherent in the data. at the time of writing. In addition, no data on ethnic Administrative data in a universal health system or minority status were available. More comprehen- have the advantage of capturing the breadth of the sive data are needed to assess quality and outcomes population but provide little clinical or risk factor of depression care in primary care, speciality care and information. They can show access to broadly defined hospital settings. categories of care, but cannot illustrate the quality or adequacy of care received. Administrative data also For example, there is a lack of measurable indicators for are uneven in the accuracy of what they record. For depression care outside of the formal medical setting— example, in the OHIP data, diagnostic information is not audited and is limited to one field. Individuals with both depression and another illness may have their physician visit attributed to that other illness, leading to under-counting of depression care. On the other hand, they may be over-counted—one of the codes used to identify depression in this chapter (OHIP diagnostic code 300) is non-specific and also the single most frequently used code by primary care physicians.78 were unable to address that gap, largely because we do not know what types of prevention and promotion activities are most effective for depression.135 The thinking is that targeted initiatives aimed at groups at greater risk for developing depression are effective,42 but there is limited evidence on which methods work for which groups. of the population. For example, we could not assess of information on individuals, may be influenced monitoring of antidepressant therapy for those under by reporting biases, recall biases and subjective interpretation of the participants. Census data, which 78 specifically, for prevention and promotion activities. We Some indicators could only be measured for a subset Survey data, while they usually contain a wealth were used in this chapter to define neighbourhood Some domains lacked adequately researched indicators. age 65. The need to closely monitor antidepressant therapy is important for all age groups. Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion Finally, there were evidence-based indicators for or electroconvulsive therapy). Such small numbers are which Ontario data were available but could still not a problem both statistically (because they cannot be be reported. Despite relatively large sample sizes (the reported with any confidence) and ethically (because smallest being 39,000 Ontarians in the CCHS 1.1 reporting them might violate privacy and confidentiality survey) these indicators measured events that were very guidelines). We suspect similar limitations will apply to rare. Small sample sizes prevented us from reporting many clinically important measures, particularly those the percentage of ‘depressed’ individuals who were on interventions or outcomes specific to subgroups of either taking medication or had a physician visit for people suffering from depression. depression, who had a serious outcome (such as a suicide attempt, an emergency room visit for depression Key Messages Our findings support the need to re-evaluate care for • Explore developing care models for specific underserved depression in Ontario along several fronts and at several groups (including men, younger people, the elderly, levels. The indicators chosen for this chapter arise from people with low incomes and people who live in rural evidence-based recommendations or guidelines for areas) and evaluate their impact, especially when appropriate depression care and suggest specific and combined with targeted outreach; immediate aspects of clinical practice that need further examination and improvement. The distribution and organization of existing resources—an important element in supporting the continuity of care envisioned across the decades of Mental Health Reform in • Implement models to better coordinate care through transition periods between sectors, particularly from hospital to home; • Coordinate depression care with other types of health Ontario and an obvious focus for the newly organized care, particularly chronic disease management, so that LHINs—will also play important roles in both improving patients with more than one health problem do not access and delivering more appropriate and effective receive fragmented care; courses of care in the immediate and medium term. In • Evaluate the effectiveness of care through routine particular, a wider adoption of collaborative care models gender and equity analyses of indicators of depression for depression deserves serious consideration. care and its outcomes; The following actions could help to improve access to, and the quality of, depression care in Ontario: • Develop and support collaborative care models in • Improve data capacity to better measure access, quality and outcomes of depression care across the care continuum. primary care and across depression care sectors; Improving Health and Promoting Health Equity in Ontario 79 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Improving Depression Care: Different Approaches In this chapter we present results pertaining to patterns of depression care in Ontario with a focus on gender and equity issues. We identified many opportunities for improvement. Measurement is only the first step towards improving care physicians are provided the support they need care. Once gaps in care are found, identification and to effectively manage depression and ready access to implementation of interventions to improve care are mental health professionals for both shared care and essential next steps. Quality improvement interven- referral for more complex cases. Patients are commonly tions can take many forms, but are usually targeted provided with self-management support. An adaptation at the policy, practice, provider or patient levels or a of the collaborative care model for people on short-term combination of these. Because women have different disability leave for psychiatric disorders in Ontario was patterns of depression and different experiences found to be effective in a recent trial.140 with care, the provision of depression care should be sensitive to these differences. There are a number of evidence-based interventions available to improve depression care. In addition, much work in Ontario and internationally is aimed at developing new approaches to improving access, quality and outcomes of care Collaborative care has proven effective at improving both short- and long-term depression outcomes as well as reducing gender, socioeconomic and racial disparities in care.52, 72, 118 In addition, the model is effective across age groups including older adults141 and adolescents.129 among individuals with depression. Below we provide Multiple large scale randomized controlled trials have selected examples of both well studied, evidence-based found collaborative care for depression to be effective. interventions to improve depression care as well as However, knowledge that a model works does not emerging models where there is some evidence that necessarily ensure that the model will be widely they can lead to improvements in care, but the evidence implemented. Much work has been done to implement is limited. these models into real-world primary care practice and there is growing evidence on how to do this effectively. Collaborative care Large scale projects that have made headway in A body of evidence from randomized controlled trials developing quality improvement strategies to implement and supported by systematic reviews has found col- collaborative care models into real-world primary care laborative care models to be an effective approach for practices include Improving Mood-Promoting Access improving quality and outcomes of depression care to Collaborative Treatment (IMPACT), Re-Engineering in primary care settings.72, 136-138 This approach uses a Systems for Primary Care Treatment of Depression team of health professionals (including primary care (RESPECT-Depression) project142-144 Partners in Care145, 146 physicians, allied health professionals and psychiatrists) and Translating Initiatives for Depression into Effective to ensure proactive treatment and follow up care of Solutions (TIDES) project.147-149 For example, IMPACT is depressed patients (see the Discussion).137, 139 Primary an effective collaborative care model for older adults 80 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion that incorporates a depression care manager, routine The National Alliance on Mental Illness (NAMI) outcomes assessments, psychiatric consultation when undertook the goal of promoting the ACT model in needed and a stepped care approach.141, 150, 151 IMPACT order to improve access to this evidence-based service- has been implemented into many settings.129, 152-154 delivery model.165 Through strong advocacy, education Many of these programs have also made materials and dissemination of implementation resources, NAMI and resources available online to assist clinicians and has created a grassroots demand for ACT programs organizations interested in adapting and implementing and has worked with providers to establish ACT the projects into their unique care settings.142, 145, 155 programs.166 Examples of successful implementation of this model are also available on the IMPACT website. The Implementing Evidence-Based Practices for Severe Mental Illness project,166, 167 an initiative to improve These projects have shown quality improvement efforts access to empirically supported practices for people in primary care settings can improve depression care with severe mental illness, has developed and made and outcomes of depressed patients. available an Assertive Community Treatment Evidence- 12-14 Based Practice KIT to aid service providers in implementAssertive community treatment ing ACT services.168 Assertive community treatment (ACT) is a communitybased model for delivering treatment and support to people with severe and persistent mental illness, including severe depression. Rather than a case-management system which provides referrals to outside services, ACT services are delivered directly by a multidisciplinary team of service providers who have expertise in areas of psychiatry, social work, nursing, substance abuse treatment and vocational training. These services are delivered in home or community settings and are available 24 hours a day, 7 days a week. 156 It is often challenging to adapt a model implemented in a rigorously designed trial into routine practice. ACT models have been implemented in Ontario. However, a recent study identified challenges to full implementation of the model.169 These findings have led to changes to the implementation strategy, illustrating the importance of formally evaluating practice innovations and improvement initiatives. Performance measurement and reporting Performance measurement and reporting is one Multiple studies from the US have shown ACT programs strategy for improving health care quality. Important can reduce hospital days, while improving quality of progress has been made in the development and life and functioning.157-161 ACT has also been shown to testing of quality indicators for depression care in improve additional outcomes such as increased housing both ambulatory care and hospital settings, though stability and reduction in jail days. ACT programs indicator development in this area lags behind other have been show to be cost-effective when the model sectors.86, 170-172 In the US, the National Committee is faithfully implemented and high risk patients are on Quality Assurance’s (NCQA) Health Plan Employer targeted.162 Studies from the UK and Europe have Data and Information Set (HEDIS), a tool used by had more modest results when comparing ACT to more than 90 percent of American health plans to community mental health care teams, which may in measure performance on important dimensions of part reflect the effectiveness of usual mental health care, contains five measures relating to mental health care in those settings.163, 164 These trials found improved (three assessing the management of antidepressant patient engagement, satisfaction and reduction in loss therapy in ambulatory care settings and two assessing of contact with the mental health system.163, 164 follow up care after hospitalization for mental illness). Improving Health and Promoting Health Equity in Ontario 81 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Recently an expert consensus process was used to advocacy, education, indirect and direct client interven- identify a set of fifteen quality indicators to assess tion and follow up. It was developed to eliminate gaps hospital care for mental illness, including measures in mental health care and build collaborative cultures for care coordination in the transitions from home to between the local hospital, physicians' offices, mental hospital and back to the community.172 health clinics, and community agencies. The goal was The impact of measurement and reporting of HEDIS depression measures has been assessed. Only modest improvements have been made on these performance measures over time and rates of improvement have been much smaller than for other chronic to address unmet need for mental health services in this rural community.175 In Winnipeg, psychiatric emergency nurses based in emergency departments have been used to support the care of patients presenting to the emergency department for mental health problems.176 One challenge in implementing the mental health conditions.73, 86, 170, 171 This finding underscores liaison role has been clear definition of the roles and the unique challenges to improving mental health care and the need for health system redesign to achieve improvements in depression care. responsibilities of the mental health liaison. More information is needed on the impact of this role in different care settings on patient outcomes as well as Furthermore, there is need for development of on the cost effectiveness of different models of this more comprehensive and sensitive indicators in function. depression care. E-Health and web-based interventions Integration and coordination of mental health E-health and web-based interventions are increas- services ingly being used to improve access to depression care The need to integrate and coordinate mental health and provide self-management support and depression services across the continuum of care (see Figure 1) education to patients, support primary care physicians, is well recognized and local systems are working to integrate and coordinate depression care and provide implement innovative approaches to this problem. early intervention and prevention.121-123 Telemedicine However, there is limited evidence as to how do this most effectively and efficiently. Nevertheless, a number of approaches show promise, albeit evaluated in single systems of care with limited data on patient outcomes. can be used increase access to mental health professionals. One randomized control trial found telemedicine effective in adapting the collaborative care model of depression care to rural communities. The Ontario Care coordinators have been shown to improve Telemedicine Network is using telemedicine to deliver outpatient follow up both at 7 days and 30 days after psychiatric care to those who otherwise would have a psychiatric hospitalization.173 Nurse-led mental health difficulty accessing these services (see the Discussion). liaison services have been implemented in Australia and the United Kingdom.174 The mental health liaison nurse serves as a care coordinator, provides support to patients, education and support to providers, and may function as a member of a multidisciplinary team providing care.174 There are a growing number of web-based interventions for depression directed both at patients and providers. The internet also holds promise as a tool for prevention, diagnosis and management of depression. Delivery of both patient information on depression and online cognitive behavioural therapy has been shown to In Canada, one Alberta Health Region has implemented improve depression outcomes in a randomized control a mental health liaison role in a rural community. The trial in Australia.121, 123 The investigators hypothesized role was filled by a mental health nurse who provided 82 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Discussion that providing depression education and training in been shown to reduce racial disparities in depression cognitive behavioural therapy to adolescents and care.52, 183 One study found that racial differences in young adults can foster resilience and behaviours to receipt of counselling was explained by education, help prevent depression. This web-based program also employment status and insurance status.181 Thus, care provides self-management support to patients receiving needs to be provided in the context of intersecting depression care.121 A web-based screening instrument factors of gender, ethnicity and socioeconomic position. for the diagnosis of depression in primary care has also It is recommended that clinicians consider patients' been tested.122 It is likely that there will be growing cultural and social context when negotiating treatment availability of a range of e-health interventions and decisions for depression.177 web-based interventions for depression. More evidence will be needed about their effectiveness for specific purposes in different settings as well as effectiveness in different population subgroups. Improving accessibility, acceptability and outcomes of depression care among racial and ethnic minorities Depression care needs to be accessible and acceptable and delivered in a culturally sensitive manner to immigrants and ethnic minorities who may have different cultural beliefs about depression and different preferences for care.177, 178 Different population subgroups may also encounter different barriers to care and have different experiences within the health care system.179 Furthermore, there is evidence that patientphysician communication may differ across diverse population sub-groups.180 Language may also provide a barrier to depression treatment. In addition to collaborative care a number of different approaches are being studied to improve the cultural acceptability and sensitivity of depression care and to improve the effectiveness of depression care to diverse populations. For example, low-income women may benefit from case management to address other social issues. The literature suggests models that allow patients to select the treatment of their choice (medication or psychotherapy or a combination) while providing outreach and other supportive services (case management, childcare and transportation) appear to result in optimal clinical benefits for disadvantaged women suffering from depression.184 A culturally tailored videotape about depression was found to be acceptable for most African Americans with depression participating in focus groups and improved knowledge and several attitudes about depression.185 While more evidence is needed on how to best tailor depression care to diverse communities and what strategies best Racial disparities in depression care in primary care have optimize outcomes the evidence supports the idea been observed but not in all studies, suggesting that the that high quality, culturally acceptable depression care presence of disparities varies across practice settings and coupled with supports that address social context that it is possible to close care gaps associated with race can lead to improved outcomes for all patients with and ethnicity. depression. 181, 182 A quality improvement intervention using the collaborative care model in primary care has Improving Health and Promoting Health Equity in Ontario 83 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Appendix 5.1 Indicators and their links to provincial strategic objectives APPENDIX 5.1 | D epression indicators: links to the Ontario Health Quality Council (OHQC) Attributes of a High-Performing Health System and the Ministry of Health and Long-Term Care (MOHLTC) Strategic Objectives Indicator Link(s) to OHQC Attributes of a High-Performing Health System Link(s) to MOHLTC Strategic Objectives • Accessible • Improve Section 5A – Background Measures Prevalence of probable depression clinical and population health outcomes • Effective • Focused on population health • Influence • Improve Health and functional status of people with probable depression • Effective • Focused broader determinants of health health status of Ontarians • Improve on population health clinical and population health outcomes • Influence broader determinants of health • Improve Rate of hospitalization for depression • Accessible health status of Ontarians • Improve clinical and population health outcomes • Effective • Influence broader determinants of health • Improve OHIP core mental health care users and OHIP core mental health care costs • Accessible • Focused health status of Ontarians • Increase on population health productive use and appropriate distribution of resources across the system • Improve access to appropriate health services Electroconvulsive therapy (ECT) use • Accessible • Effective 84 • Increase productive use and appropriate distribution of resources across the system Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.1 APPENDIX 5.1 | D epression indicators: links to the Ontario Health Quality Council (OHQC) Attributes of a High-Performing Health System and the Ministry of Health and Long-Term Care (MOHLTC) Strategic Objectives Indicator Link(s) to OHQC Attributes of a High-Performing Health System Link(s) to MOHLTC Strategic Objectives • Accessible • Increase Section 5A – Background Measures Number of general practitioners (GPs)/ family practice (FP) physicians and psychiatrists productive use and appropriate distribution of resources across the system • Improve access to appropriate health services Number of acute hospital psychiatric beds • Accessible • Increase productive use and appropriate distribution of resources across the system • Improve access to appropriate health services Section 5B – Primary and Specialty Outpatient Care Percentage of individuals with probable depression who had a physician visit for depression • Accessible Percentage of older adults starting a new course of antidepressant medication who received adequate physician follow up • Effective Percentage of women who had a physician visit for depression within one year of giving birth • Accessible • Patient-centered • Improve • Improve • Patient-centered • Patient-centered Improving Health and Promoting Health Equity in Ontario access to appropriate health services patient-centeredness • Improve safety and effectiveness of health services • Improve chronic disease management • Improve access to appropriate health services • Improve patient-centeredness 85 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 APPENDIX 5.1 | Depression indicators: links to the Ontario Health Quality Council (OHQC) Attributes of a High-Performing Health System and the Ministry of Health and Long-Term Care (MOHLTC) Strategic Objectives Indicator Link(s) to OHQC Attributes of a High-Performing Health System Link(s) to MOHLTC Strategic Objectives • Effective • Improve Section 5C – Acute and Specialty Inpatient Care 30-day post-discharge rate of physician visits for depression • Patient-centered • Integrated integration of health services providers, processes and systems • Improve safety and effectiveness of health services • Improve Average number of days post-discharge to first physician visit for depression • Accessible chronic disease management • Improve • Integrated integration of health services providers, processes and systems • Improve access to appropriate health services • Improve 30-day post-discharge rate of emergency department visits (with no subsequent hospital admission) • Accessible • Improve integration of health services providers, processes and systems • Effective • Integrated • Improve safety and effectiveness of health services • Improve 30-day readmission rate for depression • Accessible • Effective chronic disease management chronic disease management • Improve integration of health services providers, processes and systems • Improve safety and effectiveness of health services • Improve 86 chronic disease management Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.2 Appendix 5.2 INDICATORS AND THEIR SOURCES APPENDIX 5.2 | D epression indicators: indicator sources and data sources Measures and Indicators Indicator Source Data Source • A Canadian Community Health Survey (CCHS), Cycle 1.1 Section 5A – Background Measures Prevalence of probable depression Profile of Women’s Health Indicators in Canada186 • Association of Public Health Epidemiologist in Ontario (APHEO) Health and functional status of people with probable depression • A Profile of Women’s Health Indicators in Canada186 ^ • Statistics CCHS, Cycle 1.1 Canada. Health Indictors 2008^ • Association of Public Health Epidemiologist in Ontario (APHEO)^ • Report of the Consultative Meeting to Finalize a Gender-sensitive Core Set of Leading Health Indicators187^ Rate of hospitalization for depression • Hospital Report 2004: Mental Health188 Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); Registered Persons Database (RPDB) OHIP core mental health care users and OHIP core mental health care costs per capita • ICES Ontario Health Insurance Plan (OHIP); RPDB Atlas: Fee-for-Service Core Mental Health Services: Changes in Provider Source and Visit Frequency60 • Accountability and Performance Indicators for Mental Health Services and Supports: A Resource Kit189 Electroconvulsive therapy (ECT) use • Electroconvulsive Therapy in Older Adults: 13-year Trends190 OHIP; RPDB • Epidemiological Analysis of Electroconvulsive Therapy in Victoria Australia191 Improving Health and Promoting Health Equity in Ontario 87 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 APPENDIX 5.2 | D epression indicators: indicator sources and data sources Measures and Indicators Indicator Source Data Source • Accountability ICES Physician Database (IPDB); RPDB Section 5A – Background Measures Number of general practitioners (GPs)/ family practice (FP) physicians and psychiatrists and Performance Indicators for Mental Health Services and Supports: A Resource Kit189 • Psychosocial Wellbeing and Psychiatric Care in the European Communities: Analysis of Macro Indicators192 • Hospital Report 2004: Mental Health188 Number of acute hospital psychiatric beds • Accountability and Performance Indicators for Mental Health Services and Supports: A Resource Kit189 • Psychosocial Daily Census Summary Report Mental Health Beds online, Ministry of Health and Long-term Care (MOHLTC) Health Data Branch; RPDB • Continuous CCHS, Cycle 1.1; OHIP Wellbeing and Psychiatric Care in the European Communities: Analysis of Macro Indicators192 Section 5B – Primary and Specialty Outpatient Care Percentage of individuals with probable depression who had a physician visit for depression Enhancement of Quality Measurement in Primary Health Care (CEQM), BC • Women's Health Surveillance Report: A Multi-Dimensional Look at the Health of Canadian Women193 88 Percentage of older adults starting a new course of antidepressant medication who received adequate physician follow up • The National Committee for Quality Assurance (NCQA). Healthcare Effectiveness Data and Information Set (HEDIS) Ontario Drug Benefit (ODB) database; OHIP Percentage of women who had a physician visit for depression within one year of giving birth • National CIHI-DAD; OHIP; ICES Mother-Baby (MOMBABY) Linked database Health Priority Areas Report: Mental Health 1998, Australia194 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.2 APPENDIX 5.2 | D epression indicators: indicator sources and data sources Measures and Indicators Indicator Source Data Source • Hospital CIHI-DAD; OHIP Section 5C – Acute and Specialty Inpatient Care 30-day post-discharge rate of physician visits for depression Report 2004: Mental Health188 • The National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) Average number of days post-discharge to first physician visit for depression • Continuous Enhancement of Quality Measurement in Primary Health Care (CEQM), BC CIHI-DAD; OHIP • A Mental Health Program Report Card: A Multidimensional Approach Monitoring in Public Sector Programs195 30-day post-discharge rate of emergency department visits (with no subsequent hospital admission) • Hospital Report 2004: Mental Health188 CIHI-DAD; National Ambulatory Care Reporting System (NACRS) 30-day readmission rate for depression • Hospital CIHI-DAD Report 2004: Mental Health188 • Accountability and Performance Indicators for Mental Health Services and Supports: A Resource Kit189 ^ These references examine self-rated health and self-reported functional status in the general population. Improving Health and Promoting Health Equity in Ontario 89 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Appendix 5.3 How the Research was Done 1. Indicator Selection and Reporting The Working Group then reviewed these potential The indicators reported in this chapter were selected indicators using three filters. First, items that were using a modified Delphi process combined with a descriptive measures (e.g., prevalence of depression) structured literature review. The process began with a were set aside from those that were more direct review of a continuum of care framework that spanned indicators of depression care (e.g., percentage of seven types of services ranging from prevention through population receiving preventive screening). The palliative care services. The project team decided to substantial number of items identified as ‘descriptive’ exclude palliative care from consideration as issues in this process led the team to add Section 5A of this related to depression care in this setting are complex chapter as these measures provide important contextual and could not be readily assessed. information about disease burden in the population, The remaining six service types (Figure 1) were the basis need for services and patterns of care. for a survey to be completed by an expert panel. In this Second, the Working Group evaluated the remaining survey, panel members were asked to identify the two items in terms of their importance and relevance most critical issues for each service continuum point to the chapter’s purpose. Examples of items judged that represented 1) a gap between women and men less relevant include measures of specific rather than in the treatment for depression or in the exposure to broader types of intervention (e.g., lithium therapy) or negative or positive factors associated with depression of outcomes more relevant to specific program types incidence, course of the illness, access or use of services, (e.g., percent of clients employed within six months and/or outcomes and/or 2) a substantial issue in the post diagnosis). care of depression. ‘Substantial’ was defined in terms of Third, because the goal of the POWER Study was to the size of the affected population or the severity of the report actual numbers, candidate indicators were associated outcome. Participants were also to provide a reviewed in terms of whether or not they could be rationale for each issue so that these could be incorpo- measured using available Ontario-wide data. This rated into the subsequent Delphi process. feasibility filter was applied somewhat liberally with Twenty-six issues were identified by the panel (Table the intent of maximizing the number of measurable 5.1), which then served as the basis for a structured candidate indicators. In some cases, similar indicators review of both published and grey literature. One were merged into a single, more easily measured, item. hundred and twenty measures were identified through In other cases, proxy or interim measures were used as this search with primary care measures accounting ‘placeholders’ for indicators that could not be measured for the vast majority (76) followed by acute/specialty in their original form. The application of these three inpatient care (23). Because no indicators were found filters reduced the number of candidate indicators to for ‘chronic and rehabilitation care’, this continuum thirteen. point was dropped from consideration. 90 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.3 The final set of indicators was selected through a most responsible diagnosis included an ICD-10 code modified Delphi process by a Technical Expert Panel for major depression (ICD 10 codes F32, F33, F412 or using a two-step method—first through an online ques- F480). For the Ontario Health Insurance Plan (OHIP) tionnaire using explicit indicator selection criteria and physician claims’ data, the diagnostic codes were those then at a face-to-face meeting on April 4, 2007 (see that included depression (311) or reactive depression Introduction to the POWER Study, chapter 1 for a more (300) in their descriptions. detailed description of the Delphi process. See Appendix 5.1 or 5.2 for a complete list of reported indicators). The definition of a physician visit for depression used in this chapter is imprecise because it can both under- Indicators and background measures were calculated and over-report whether depression, versus other at the provincial and Local Health Integration Network conditions, was addressed during the visit. The OHIP (LHIN) levels. They were first stratified by sex and then database only allows one diagnosis per visit, irrespec- by age, income (either neighbourhood income quintile tive of the number of conditions that are addressed or annual household income), and rural/urban residency, during the visit, thus contributing to under-reporting when sample size allowed. Age-adjustment was done of depression. However, one of the diagnostic codes using indirect standardization. (300: Anxiety neurosis, hysteria, neurasthenia, obsessive compulsive neurosis, reactive depression) 2. Data Sources and Measures used to define a physician visit for depression in this The data presented in this chapter came from several chapter is overwhelmingly the one most frequently sources, including survey and administrative data. used in family physician practice, suggesting an In most cases, administrative data from fiscal year overuse of this code. This code is not specific to 2005/06 were used, however for those indicators depression, therefore, including it in the definition may based on linked administrative and CCHS, Cycle 1.1 over-report visits for depression, to some extent, and data, fiscal years 2000/01 and 2001/02 were used to may counterbalance under-reporting of depression maintain a consistent time frame. The administrative due to the one available diagnostic field.78 When this data sources that were used in producing this chapter definition is tied to a person having depression (see are described below. ’Measuring Depression’ box in the Introduction of this The indicators included measure the percentage of individuals aged 15 and older with probable depression (based on survey data) and those who chapter) or a prescription for an antidepressant, it may even more closely indicate a visit in which depression is addressed. received care for depression (based on routinely The denominators for indicators based upon 2005/06 collected administrative data or linked survey and ad- administrative data were derived from 2005 estimates ministrative data). Depression-related service contacts obtained from the Registered Persons Database (RPDB). were defined using the diagnostic information The RPDB overestimates the number of people living available in each database or, in the case of the in Ontario. This overestimate was corrected by using a Ontario Drug Benefits (ODB) database, the drug methodology that adjusts the RPDB so that population information numbers (DIN) associated with antidepres- counts by age and sex match estimates from Statistics sant medication. For the Canadian Institute for Health Canada. Information Discharge Abstracts Database (CIHI-DAD) an encounter was defined as depression-related if the Improving Health and Promoting Health Equity in Ontario 91 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Canadian Community Health Survey (CCHS) comparative picture of differences in depression care The CCHS is a nationally representative cross-sectional across sociodemographic and geographic groups. survey of the Canadian community-dwelling population Two other limitations of the CCHS, Cycle 1.1 data conducted every two years by Statistics Canada. It should be noted. First, the depression questions were is conducted via face-to-face interviews and covers optional and one Ontario public health unit/region material that alternates between a general overview (Brant) opted not to include these questions for their of the health of Canadians (the x.1 cycle surveys) and region. The impact is that the prevalence of probable more in-depth issues (the x.2 cycle surveys). Residents depression may be under- or over-reported for the living on Indian Reserves and on Crown Lands, insti- Hamilton Niagara Haldimand Brant LHIN. This may tutional residents, full-time members of the Canadian impact the overall finding that there was geographic Armed Forces and residents of certain remote regions variability in the prevalence of probable depression are excluded. and that the patterns of use and supply did not match The two surveys considered for use for this chapter on the patterns of need. Second, the CCHS, Cycle 1.1 depression were Cycles 1.1 (2000/01) and 1.2 (2002). sampling method was designed around health regions Cycle 1.2 includes a more comprehensive assessment since the LHINs did not exist at the time of the survey. of depression than Cycle 1.1. However, because the This may introduce some error into the estimates linkable version of Cycle 1.2 was not available at the reported for the LHINs. time of this reporting, only data from Cycle 1.1 were The studentized range test was used to assess the used. significance of differences among the rates. For the Background measures and indicators using the CCHS indicators based on the CCHS, Cycle 1.1 data, the data were restricted to Ontario respondents aged 15 standard errors of the rates and 95 percent confidence and older since depression is an illness that appears intervals were calculated using 500 bootstrap weights in the late teens as well as in later years. Past-year provided by Statistics Canada. In addition, relative rates depression was measured in Cycle 1.1 using a cut-off were calculated for women-to-men, lowest-to-highest score of 0.9 on the Composite International Diagnostic neighbourhood income quintile and rural-to-urban Interview-Short Form for Major Depression (CIDI-SFMD). residence. The CIDI-SFMD probability score of >0.9 was considered Statistics Canada rules were followed in the reporting of to predict probable depression. Since the CIDI-SFMD estimates using the Ontario share file as follows: was designed to predict the probability that a person would be considered depressed using the full set of CIDI depression questions (as was done in Cycle 1.2), it may somewhat overestimate prevalence. The prevalence of depression based on Cycle 1.2 was 4.8% (6.1% of women, 3.5% of men) compared to the rate of 7.4 • Estimates should not be reported if the unweighted sample is less than 10 • Estimates are adequate and can be reported if the coefficient of variation is 16.5 or less • Estimates should be reported with caution if the (9.8% of women, 4.9% of men) from Cycle 1.1 which is reported in this chapter. It should be noted that the CIDI-SFMD has not yet been fully validated.196 Thus coefficient of variation is between 16.6 and 33.3 • Estimates should be suppressed if the coefficient of variation is greater than 33.3 the prevalence reported here is not precise and very likely somewhat overestimates the actual population prevalence. However, it is still useful in providing a 92 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.3 Ontario Health Insurance Plan (OHIP) The Ontario Drug Benefit Program (ODB) The OHIP claims database covers all reimburse- The ODB database contains information about the use ment claims to the Ontario Ministry of Health and of medications, including antidepressants, in Ontarians Long-Term Care, made by fee-for-service physicians, aged 65 and older as well as individuals on welfare community-based laboratories and radiology facilities. assistance who are covered by the ODB. The ODB The OHIP database at ICES contains encrypted patient tracks all filled prescriptions for medications listed in its and physician identifiers, code for service provided, Formulary. date of service and the associated diagnosis and fee paid. Services which are missing from the OHIP claims ICES Physician Database (IPDB) data include: some lab services, services received in The IPDB contains information on physician demo- provincial psychiatric hospitals, services provided by graphics and specialty training. The IPDB incorporates health service organizations and other alternate funding information from the Corporate Provider Database plans, diagnostic procedures performed on an inpatient (CPDB), the Ontario Physician Human Resource Data basis and lab services performed at hospitals (both Centre (OPHRDC) database and the OHIP database inpatient and same day). Also excluded is remuneration of physician billings. The CPDB contains information to physicians through Alternate Fee Plans (AFPs). Their about physician demographics, specialty training and concentration in certain specialties or geographic areas certification and practice location. This information is could distort the analysis. validated against the OPHRDC database, which verifies this information through periodic telephone interviews Canadian Institute of Health Information with all physicians practicing in Ontario. The number Discharge Abstracts Database (CIHI-DAD) of physicians per 100,000 population was derived The CIHI-DAD is a database of information abstracted from the IPDB and census population estimates for from hospital records. It includes patient-level data 2005. for acute and chronic care hospitals, rehabilitation hospitals and day surgery clinics in Ontario. The main ICES Mother-Baby (MOMBABY) Linked Database data elements of the CIHI-DAD database are encrypted The MOMBABY dataset is a cumulative database patient identifier, patient demographics (age, sex, created by linking the CIHI-DAD inpatient admission geographic location), diagnoses, procedures and ad- records of delivering mothers to those of their ministrative information (institution number, admission newborns. The linking algorithm makes use of maternal category, length of stay). and newborn chart numbers, institutions, postal codes, admission/discharge dates and procedure codes. The National Ambulatory Care Reporting System database includes information on maternal gestational (NACRS) age at admission and at delivery, newborn gestational NACRS is a data collection tool used to capture patient weeks at delivery and flags that identify multiple births and clinical information on patient visits to hospital and still births. and community-based ambulatory care: day surgery, outpatient clinics and emergency departments. It is currently mandated in Ontario for emergency department, day surgery, dialysis, cardiac catheterization and oncology facilities. Improving Health and Promoting Health Equity in Ontario 93 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Linked Data Measures (Administrative and/or estimates were calculated by DA. Ontario neighbour- Survey Data) hoods are classified into one of five approximately The linked indicator for individuals with probable equal-sized groups (quintiles), ranked from poorest (Q1) depression was defined using the CCHS, Cycle 1.1. to wealthiest (Q5). These income quintiles are used CCHS data were linked to the administrative data using as proxy for overall SES, which has been shown to be the scrambled unique identifier available across all the related to population health status and levels of health databases used in this chapter. The time period for the care utilizations. Individual geographic information administrative data included was based on the CCHS from ICES databases was used to define the best interview date and the indicator. The linkage was with known postal code for each person on July 1 of each administrative records within one year after the CCHS year (available from 1991 to 2004). Postal codes were interview. then used to assign people to Enumerations Areas (EAs) or Dissemination Areas (DAs) (using the Statistics Indicators for depression (e.g., physician visits for Canada Postal Code Conversion File) and thus to one depression) were defined using the diagnostic of the income quintiles. EAs and DAs are small adjacent information in the various administrative data as described earlier. The date of the referent event (e.g., hospital discharge) was used to determine the time geographic areas, designated for collection of census data. DAs replaced EAs in 2001 and have a population of 400–700 persons. period of the other administrative data to be linked (e.g., emergency department (ED) visit within 30-days post-discharge). Annual Household Income Annual household income was collected in the CCHS, Cycle 1.1. Taking the number of household members 3. Regional and Socioeconomic Variables into consideration, annual household income was Patients Residence classified into four categories: low income, lower For all analyses presented in the report, the definition middle, middle or higher income. Low income was of ‘Local Health Integration Network (LHIN) of patient defined as <$15,000 for 1 or 2 household members, residence’ is based on the postal code of the individual <$20,000 for 3 or 4 household members or <$30,000 at the time of completing the survey for CCHS data, the for 5 or more household members. Lower middle postal code at the time of discharge for CIHI-DAD data income was defined as $15,000 to $29,999 for 1 or the postal code of the individual as of July 1, 2005 or 2 household members, $20,000 to $39,999 for for data from OHIP or the ODB. 3 or 4 household members or $30,000 to $59,999 for 5 or more household members. Upper middle Income Quintile income was defined as $30,000 to $59,999 for 1 or 2 Average neighbourhood income is calculated by household members, $40,000 to $79,999 for 3 or 4 Statistics Canada and is updated every five years household members or $60,000 to $79,999 for 5 or when new Census data become available. Income more household members. Higher income was defined was calculated using the neighbourhood income per ≥$60,000 for 1 or 2 household members or ≥$80,000 person-equivalent (IPPE), which is a household-size for 3 or more household members. adjusted measure of household income based on 2001 census summary data at the dissemination area (DA) and using person-equivalents implied by the 2006 low income cut-offs (LICOs). In 2001, average income 94 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.3 Location of Residence (Rural Versus Urban) Because of issues of sample size and high sampling Rural/urban residency was assigned based on postal variability of the responses to these questions, we report code and using the Statistics Canada PCCF+ macro to the indicators as described above. assign locations. Community size was derived from the Statistics Canada 2001 Census data. Communities of Measures of Health Service Use 10,000 or fewer residents were defined as rural. All Administrative data were used to measure health other communities were classified as urban. service use. While the original intent was to include the 12-months of data within a single fiscal year (i.e., from Standardization April 1 to March 31), this had to be modified. CIHI-DAD All indicators were age-adjusted to the study cohort and NACRS data are released for analyses in 12-month using indirect standardization. blocks corresponding to a fiscal year. However, two indicators (30-day readmission rate and 30-day post- 4. BACKGROUND MEASURES AND INDICATORS discharge rate of ED visits) required the capability of following up one month after the fiscal year ended. Prevalence of Depression The solution was to shift the 12 months back by one The prevalence of depression was measured using month—that is from March 1 to February 28. the CCHS, Cycle 1.1. Respondents who scored 0.9 or higher on the Composite International Diagnostic Interview-Short Form for Major Depression (CIDI-SFMD) were classified as having probable depression. Health and Functional Status CIHI-DAD was used to measure the number of hospital admissions from March 1, 2005 – February 28, 2006 per 100,000 population aged 15 and older with a most responsible diagnosis of depression (ICD 10 codes F32, F33, F412 or F480). Self-rated health, comorbidity and functioning were OHIP data were used to measure the proportion of assessed using four measures from CCHS, Cycle Ontarians aged 15 and older who saw a physician for 1.1—the percentage of Ontarians with probable assessment, diagnosis or treatment of a mental health depression who rated their health as fair or poor, those condition (OHIP diagnosis codes 300 or 311) during the who indicated they had no other chronic medical period March 1, 2005 – February 28, 2006. The fees conditions, the average number of days in the previous associated with these visits, based on OHIP fee codes, two weeks spent out of bed for all or most of the day were used to calculate the average cost per capita paid and the average number of days in the previous two for these core mental health services. weeks when the person did not have to cut down on OHIP data were also used to measure the number of normal activities. The last two measures of functional electroconvulsive therapy (ECT) users from March 1, status were derived from the following CCHS questions: 2005 – February 28, 2006 per 100,000 population aged • During the past 14 days, did you stay in bed at all 15 and older defined as any individual for whom a code because of illness or injury, including nights spent as a of G478 or G479 (electroconvulsive therapy cerebral) patient in a hospital? was billed. • Not including bed days, during those 14 days, were there any days that you cut down on things you normally do because of illness or injury? Improving Health and Promoting Health Equity in Ontario 95 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Measures of Supply Women Who Had a Physician Visit for Depression Administrative data were used to measure supply of After Giving Birth medical services. The IPDB was used to identify the CIHI-DAD was used to identify women who were number of general practitioners/family physicians and discharged from hospital (from March 1, 2005 - the number of psychiatrists available in Ontario per February 28, 2006) after having given birth. Still births 100,000 population aged 15 and older. The number were excluded. This cohort was linked, using encrypted of acute care psychiatric beds available in Ontario was health card numbers, to the OHIP database to identify based on estimates available from the Ministry of Health physician visits for depression (OHIP diagnosis codes and Long-Term Care’s (MOHLTC) Health Data Branch. 300 or 311) within one year of hospital discharge. The report was accessed on February 6, 2008 at http:// www.mohltcfim.com/cms/client_webmaster/index.jsp Physician Visits, Emergency Department Visits and Readmissions Following Discharge from a Physician Visits for Depression Hospital Stay for Depression Ontarians with probable depression, based on CCHS, These indicators included all discharges from acute care Cycle 1.1 were linked (using encrypted health card hospitals and those psychiatric hospitals included in numbers) to OHIP data (from the 2000/01 and 2001/02 the CIHI-DAD from March 1, 2005 - February 28, 2006 fiscal years) to identify the number of people with after an admission for depression (ICD10 codes F32, probable depression who were seen by a physician for a F33, F412 or F480). depression-related visit during the year after the survey date. OHIP diagnostic codes 300 or 311 were used to identify ‘depression-related’ visits. • Discharge records for patients admitted to hospital for depression were linked to the OHIP database, using encrypted health card numbers, to determine the Physician Follow Up for Patients On a New Course of Antidepressants The ODB was used to identify patients who started on a new course of antidepressants and who filled two or percentage that were seen by a physician for depression (OHIP diagnostic codes 300 or 311) within 30 days, 12 weeks, six months and one year of discharge. The mean number of days to the first visit was also calculated. more prescriptions within 100 days (first prescriptions • Discharge records for patients admitted to hospital for filled during the period March 1, 2005 - February 28, depression were also linked to the NACRS database, 2006). The sample was restricted to adults aged 66 using encrypted health card numbers, to identify the and older to allow review of data from one year prior percentage of patients that were seen in an emergency to confirm that the medication use represented a new department for any reason within 30 days of discharge prescription. This cohort was linked, using encrypted without a resulting hospital admission. health card numbers, to the OHIP database to identify • Patients who were discharged from hospital after an physician visits for depression (OHIP diagnosis codes 300 admission for depression were followed for 30 days or 311) within 12 weeks of starting medication. Three from the date of discharge to identify patients who or more visits during the acute period of treatment are were readmitted to hospital for depression within 30 recommended.86 days of discharge. 96 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.3 5. ANALYSIS Bivariate analyses were used to estimate differences by sex. Differences were also estimated by age, neighbourhood income quintile, rural/urban residency, and Administrative data have the following limitations that should be considered when interpreting findings from these data: • Although coders undergo extensive training and LHIN and, where the numbers permitted, by sex within rechecking procedures, variations in interpreting coding these variables. Indicators based on CCHS data were and reporting guidelines and in hospital practices may weighted to represent the demographic makeup of the create biases in hospital administrative data. Ontario population during the survey year. For indicators based on administrative data, indirect age-standardization, using the 2005 Registered Persons Database (adjusted for the Statistics Canada Census) was applied. Where numbers were too small, results were either not reported or were aggregated. Limitations The results based on CCHS data should be interpreted with caution for the following reasons: • The survey relies on self-reports and voluntary participation of randomly selected participants, and thus the • Physician claims data have one field for diagnostic information. Anecdotal information suggests variation in coding across medical specialties and when patients present multiple conditions during a single visit. While cross-province comparisons provide some evidence for the reliability of physician coding at a gross level,61 there are likely biases and omissions when using these data to identify visits for depression. The following cautions should be kept in mind when data for the ecological variables (SES, rural/urban) are interpreted: data reflect individuals’ interpretation of questions and • Accuracy of the information depends on the accuracy how they perceive their own health. Hence, results may of the data provided to the census or the Ministry of be an under- or over-estimation of the prevalence of Health and Long-Term Care (RPDB). some conditions. • The CCHS does not survey Aboriginal people living on • Data definitions may differ (e.g., urban vs. rural) for various reasons such as changes in population con- reserves, institutionalized individuals, individuals unable centration or composition or use of different analytic to be surveyed in English or French, or persons in the thresholds (e.g., using quartiles vs. quintiles). armed forces. While the findings pertain to a large proportion of Ontarians (those living in households), they may be biased if the group not surveyed have significantly different need or utilization rates. • The CCHS survey was conducted before LHINs were created and there was inadequate sample size for some measures for some LHINs. This prevented comparative analysis of some indicators. Improving Health and Promoting Health Equity in Ontario 97 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 TABLE 5.1 | S ummary of critical issues vis-à-vis care for depression from expert panel survey Care for depression continuum point Issue Prevention 1. Few gender-specific prevention/public education programs 2. Need programs designed to prevent exposure to likely risk factors and/or support to at-risk subgroups should be based on evidence • Programs • Populations/factors to be targeted: Poverty/low income and depression for women Parental history of mental illness Childhood maltreatment Low SES women with children Men – recognition and treatment of depression Workplace stress Postpartum period for women Community Services/Supports 3. Few gender specific community services/supports programs 4. Accessibility of such programs (e.g., child care options, non-business hours) 5. [gender-specific] Acceptability of such programs 6. Clinics need to follow current guidelines regarding identifying and either referral or treatment for depression 7. Vocational support programs need gender-sensitive case finding and intervention programs 8. Men less likely to access these services. Mental health stigma is higher for men and male adolescents who have a higher dropout rate in treatment programs Primary Care 9. Women should be screened for depression (especially postpartum and premenopausal) 10. Need better access (for all) to primary care and especially family physicians 11. Training and capability of primary care providers to recognize and treat mild to moderate depression 12. Need for primary care to follow guidelines for assessment and treatment of depression 13. Need for [equitable] interconnection between primary and other types of care, e.g., • Availability of specialty services that primary care can refer to • Encouragement • Access • Need of shared care arrangements to services outside the ones funded by province (e.g., psychologists) to evaluate if referrals are gender-specific • Need to evaluate whether current fee-for-service payments result in perverse incentives 98 Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Appendix 5.3 TABLE 5.1 | S ummary of critical issues vis-à-vis care for depression from expert panel survey Care for depression continuum point Issue Primary Care 14. More consistent offering and greater availability of evidence-based psychotherapy as supplement/-alternative to anti-depressants (to counteract potential overuse of biologicals in affected population which are mostly women) 15. Need to address stigma—e.g., women viewed as weak and not trying hard enough to cope with depression. This negatively impacts help-seeking behaviour and impedes recovery Acute Hospital Care 16. Bed accessibility 17. Impact of gender on the decision to admit to hospital 18. Need to incorporate the demands of women’s roles as mothers and wives into the care process. • Assessment and care need to explicitly consider the depressed woman’s role as mother and wife • Inclusion in discharge planning for possible need to assistance in caring for home/family • Marital relationships are predictor of recovery and/or relapse. Marital therapy/ counselling is often not offered at discharge Specialty Hospital Care Same as #16 - #18 19. Availability of gender-segregated units/wards 20. Relationship of length of stay for mental health [depression] reasons to gender 21. Need to link to community and primary care services so that inpatient stay is a short episode in a continuum of care 22. Need for improved community nursing teams to act as case managers and care coordinators for individual with severe mental illness Chronic & Rehabilitation Care Same as #18 23. Cost of non-insured services and medications 24. More attention to work environment regarding readiness to return to work. Management training and occupational health policies should be targeted. 25. Sheltered accommodation 26. Meaningful employment opportunities Improving Health and Promoting Health Equity in Ontario 99 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 Reference list (13) Wells KB, Sherbourne C, Schoenbaum M, Duan N, (1)Murray CJ, Lopez AD. World Health Organization's global burden of disease report, 1996. (2) Cheung AH, Dewa CS. Canadian Community Health Survey: major depressive disorder and suicidality in adolescents. Health Policy 2006;2(2):76-89. Meredith L, Unutzer J, et al. 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Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study Depression | Reference List (190)Rapoport MJ, Mamdani M, Herrmann N. Electroconvulsive therapy in older adults: 13-year trends. Can J Psychiatry 2006;51(9):616-619. (191)Wood DA, Burgess PM. Epidemiological analysis of electroconvulsive therapy in Victoria, Australia. Aust N Z J Psychiatry 2003;37(3):307-311. (192)Carta MG, Kovess V, Hardoy MC, Brugha T, Fryers T, Lehtinen V, et al. Psychosocial wellbeing and psychiatric care in the European communities: analysis of macro indicators. Soc Psychiatry Psychiatr Epidemiol 2004;39(11):883-892. (193)DesMeules M, Stewart DE, Kazanjian A, McLean H, Payne J, Vissandjée B. Women's health surveillance report: a multi-dimensional look at the health of Canadian women. Ottawa: Canadian Institute for Health Information, 2003. (194)Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare. National health priority areas report: mental health 1998. Canberra: Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, 1999. (195)Rosenheck R, Cicchetti D. A mental health program report card: a multidimensional approach to performance monitoring in public sector programs. Community Ment Health J 1998;34(1):85-106. (196)Statistics Canada. Indicators based on Statistics Canada (STC) surveys. Accessed September 9, 2009 at http:// www.statcan.gc.ca/pub/82-221-x/2007001/qualityqualite/4063856-eng.htm. Improving Health and Promoting Health Equity in Ontario 109 ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5 funder Echo: Improving Women’s Health in Ontario Echo’s mission is to improve the health and wellbeing of Ontario women and to reduce health inequities. We believe that through knowledge transfer and gender-based analysis, Echo will improve the health of women and overall quality of life, relationships, families and communities in Ontario. Long-Term Care and is working to ensure Ontario is at Echo is an agency of the Ministry of Health and the forefront of improving women’s health. partners St. Michael’s Hospital St. Michael’s Hospital is a vibrant academic teaching hospital in the heart of downtown Toronto. The physicians, nurses and staff of St. Michael’s Hospital provide compassionate care and outstanding medical education. Critical care, trauma, heart disease, neurosurgery, diabetes, cancer care and care of the homeless and vulnerable populations in the inner city are among the Hospital’s areas of excellence. St. Keenan Research Centre at the Li Ka Shing Michael’s Hospital is recognized and respected around Knowledge Institute Founded in 1892 and the world for leading-edge research that is bringing affiliated with the University of Toronto, the Hospital is new discoveries to patient care through the downtown Toronto’s designated adult trauma centre. Institute for Clinical Evaluative Sciences ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of health care issues. 110 Our unbiased evidence provides measures of health resources. ICES knowledge is highly regarded in Canada system performance, a clearer understanding of the and abroad, and is widely used by government, shifting health care needs of Ontarians, and a stimulus hospitals, planners, and practitioners to make decisions for discussion of practical solutions to optimize scarce about care delivery and to develop policy. 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